Worldwide Incidence and Prevalence of Neuromyelitis Optica: A Systematic Review

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.

Clinical and immunological differences between primary and autoimmune-associated neuromyelitis optica spectrum disorders: a retrospective study

INTRODUCTION

Neuromyelitis optica spectrum disorder (NMOSD) is a rare immune-mediated disease affecting the spinal cord and optic nerves. While NMOSD has been widely studied, limited data exist on the subset associated with autoimmune diseases (AD-NMOSD), particularly in Taiwanese patients. Additionally, relapse and prognostic factors in AD-NMOSD remain unclear.

METHODS

We retrospectively analysed 71 NMOSD cases diagnosed between 2008 and 2023 at Taipei Veterans General Hospital. Clinical features, laboratory findings, autoimmune comorbidities, imaging and treatments were examined. Patients were stratified by relapse status and the presence of severe sequelae.

RESULTS

Among 71 NMOSD cases, 26 (37%) patients had AD-NMOSD. While no significant differences were observed in the number or severity of relapses and sequelae between AD-NMOSD and primary (p)-NMOSD, patients with AD-NMOSD exhibited lower white blood cell counts, haemoglobin, platelet counts, immunoglobulin G and C reactive protein levels. Specific risk factors for relapse in AD-NMOSD included onset age under 50 years, concurrent SLE and a longer duration of SLE before NMOSD presentation. In both AD-NMOSD and p-NMOSD, more relapses were associated with severe neurological sequelae. Although relapse-free survival did not differ significantly between the two groups, patients with AD-NMOSD tended to have a longer period without severe sequelae.

DISCUSSION

Taiwanese patients with AD-NMOSD show distinct laboratory characteristics compared with those without autoimmune diseases. Younger age and longer disease duration are key risk factors for relapses, which are linked to more severe neurological sequelae. Despite various treatments, no significant differences were found in relapse rates or sequelae severity, highlighting the need for personalised management strategies.

Concomitant Sjögren's disease in patients with NMOSD: impacts on neurologic disease severity and recurrence

BACKGROUND

We aimed to characterize the phenotype of neuromyelitis optica spectrum disorder (NMOSD) in the presence and absence of Sjogren's disease (SjD) and to develop a predictive nomogram to evaluate the risk of coexisting SjD within a single tertiary-center cohort of NMOSD patients.

METHODS

Paraclinical and clinical features of patients with SjD were compared between NMOSD patients with SjD and those without SjD. Zstats v1.0 was utilized to randomly allocate participants into a derivation group (108 patients) and a validation group (47 patients) at a ratio of 7:3. Logistic regression analysis was used to assess the effectiveness of our predictive model, and a nomogram was created to illustrate the findings.

RESULTS

A total of 155 NMOSD patients who were serologically positive for AQP4-IgG were cross-sectionally recruited (70 NMOSD patients with SjD [45.16%] and 85 NMOSD patients without SjD [54.84%]). Independent predictors of coexisting SjD were age upon recruitment (P = 0.002); Expanded Disability Status Scale (EDSS) score (P = 0.023); blood white blood cell (WBC) count (P = 0.049); and rheumatoid factor (RF) (P = 0.049), anti-SSA (Ro), and anti-SSB (La) antibody positivity (P < 0.001; P = 0.012). The nomogram had an area under the receiver operating characteristic (ROC) curve (AUC) (95% confidence interval [CI]) of 0.95 (0.89, 1.00) in the derivation cohort and 0.91 (0.79, 1.00) in the validation cohort. Survival curve analysis revealed that the EDSS score in the NMOSD patients with SjD was associated with clinical relapse, and these patients reached an EDSS score of 4.0 earlier than those without SjD.

CONCLUSION

NMOSD patients with SjD manifested more severe disease at attack and relapsed earlier than those without SjD. The nomogram established by combining age upon recruitment; EDSS score; blood WBC count; and RF, anti-SSA (Ro), and anti-SSB (La) antibody levels can significantly predict the risk of NMOSD combined with SjD.

Epidemiology of aquaporin-4 seropositive neuromyelitis optica spectrum disorder in the Alicante health area, Spain: A population-based study

BACKGROUND

Neuromyelitis optica spectrum disorder (NMOSD) is an uncommon antibody-mediated inflammatory disease. The prevalence and incidence of NMOSD vary widely between geographical areas and ethnicities. To date, the only epidemiological study on NMOSD conducted in Spain has estimated an incidence rate of 0.63 per 1,000,000 person-years and a prevalence rate of 0.89 per 100,000 individuals in the general population. This population-based study aimed to estimate the incidence and prevalence of aquaporin-4 (AQP4)-seropositive NMOSD in the Alicante Health Area, Southeastern Spain, according to the 2015 International Panel for NMO Diagnosis (IPND) criteria and to investigate potential clinical and epidemiological differences that may exist in Spain in relation to NMOSD.

METHODS

In this retrospective population-based study, all patients diagnosed with AQP4-seropositive NMOSD according to the 2015 IPND criteria were identified using multiple sources. Seropositivity for AQP4 was confirmed in all cases using a cell-based assay. Two neurologists assessed the compliance with the 2015 IPND criteria. Clinical, imaging and laboratory data were obtained from medical records. The prevalence and incidence of AQP4-seropositive NMOSD were calculated using the Population Information System (SIP) data from the Alicante Health Area. The incidence rate covers January 2013-January 2023. The 95 % confidence intervals (CI) were calculated for the prevalence and incidence rates using Epidat software. Age-adjusted rates were calculated by the direct method of standardisation using Eurostat's European Standard Population in 2013 (ESP 2013) and the World Health Organization's World Standard Population expected in 2000-2025 (WHO 2000-2025) as reference populations.

RESULTS

Nine AQP4-seropositive NMOSD patients were identified in the Alicante Health Area. All patients except for one were Caucasian. The female-to-male ratio was 8:1, and the median age at onset was 39 years (range: 21-77 years). Most common clinical presentation was optic neuritis (five patients), followed by longitudinally extensive transverse myelitis (three patients) and postrema area syndrome (one patient). At the time of the study, all patients were being treated with chronic immunosuppressant treatment: tocilizumab (5/9 patients) and rituximab (4/9 patients). The overall prevalence rate was 3.11 (95 % CI: 1.42-5.91) per 100,000 individuals, while the overall annual incidence rate was 1.78 (95 % CI: 0.58-4.15) per million individuals. The age-standardised prevalence rate (using ESP 2013) was 3.09 (95 % CI: 0.62-8.77) per 100,000 individuals, and the annual incidence rate was 1.74 (95 % CI: 0.70-3.61) per million individuals. In addition, the age-standardised prevalence rate to the WHO 2000-2025 was 2.56 (95 % CI: 0.81-5.83) per 100,000 individuals, and the annual incidence rate was 1.66 (95 % CI: 0.54-3.89) per million individuals.

CONCLUSION

The crude and age-standardised prevalence rates of AQP4-seropositive NMOSD in our study were higher than those reported in other European studies. Our findings underscore that the epidemiology of AQP4-seropositive NMOSD is not uniform across Europe.

Incidence and prevalence of neuromyelitis optica spectrum disorder in a contemporary, multi-ethnic cohort

BACKGROUND

Ecological comparisons suggest that neuromyelitis optic spectrum disorder (NMOSD) is more common in African Caribbean and Asian compared to White people.

OBJECTIVE

The aim is to rigorously assess susceptibility across multiple racial and ethnic groups from the same cohort.

METHODS

We conducted a retrospective cohort study of > 39 million person-years of observation from members of Kaiser Permanente Southern California. The electronic health records of individuals with at least one International Classification of Diseases (ICD) code for NMOSD were reviewed to identify persons who met 2015 diagnostic criteria for NMOSD.

RESULTS

We identified 153 NMOSD cases, 105 incident and 105 prevalent. The age- and sex-standardized incidence (2013-2022) and prevalence (2019) according to the 2020 US Census per 100,000 person-years was significantly higher in Black persons (incidence = 0.90, 95% confidence interval (CI) = 0.59-1.21; prevalence = 8.44, 95% CI = 5.52-11.36) compared to all other racial and ethnic groups. The incidence was similar among Asian/Pacific Islander (0.32, 95% CI = 0.16-0.48) compared to Hispanic people (0.19, 95% CI = 0.13-0.25) and lowest in White people (incidence = 0.13, 95% CI = 0.07-0.19).

DISCUSSION

NMOSD susceptibility is highest in Black people, followed by Asian/Pacific Islands, then Hispanic people, and lowest in White people. Studies in diverse groups of minoritized people are needed to determine whether this increased susceptibility is due to shared genetic ancestry, the ill-health consequences of racism, or both.

Differences in clinical phenotype, laboratory, and imaging manifestations between AQP4 IgG positive and AQP4 MOG IgG double negative NMOSD: How to correctly diagnose the two

Neuromyelitis optica spectrum disorders (NMOSD) is an uncommon autoimmune inflammatory demyelinating disorder of the central nervous system (CNS) and causes severe disability and even death. Aquaporin-4 immunoglobulin G (AQP4-IgG) antibody has been confirmed as the key pathogenic factor for development of NMOSD and leading to repeatting acute attacks. However, 20-40 % of NMOSD patients lack both AQP4-IgG and anti-myelin oligodendrocytes glycoproteins (MOG) IgG, in which the pathogenic factor is still unclear. There are differences in clinical, laboretory and imaiging minifestations between AQP4-IgG positive (AQP4-IgG+) and AQP4-IgG/MOG-IgG double negative (AQP4-IgG-) NMOSD. Although the treatments applied in NMOSD have made great progress, all treatments are failed in AQP4-IgG- patients. Additionally, it is hard to identify NMOSD with AQP4-IgG- from multiple sclerosis (MS). Therefore, it is suspected and challenged that AQP4-IgG could not be the only pathogenic factor in NMOSD or NMOSD with AQP4-IgG- may be a separate disorder independent of NMOSD AQP4-IgG+? It is necessary to find more pathogenic factors and to explore the new pathogenesis and treatments of NMOSD with AQP4-IgG- in the future, which has been a serious problem to be addressed by the neurology community.

Comparison of vision-related quality of life in NMOSD and MOGAD

BACKGROUND

Aquaporin-4 antibody positive neuromyelitis spectrum disorder (AQP4+ NMOSD) and myelin oligodendrocyte glycoprotein antibody disease (MOGAD) are both associated with vision loss due to optic neuritis (ON), although evidence suggests more severe structural damage in NMOSD. The validated National Eye Institute Visual Function Questionnaire (VFQ) may be used to evaluate patients' perceptions of how vision impairment affects their lives.

OBJECTIVE

To compare vision-related quality of life in AQP4+ NMOSD and MOGAD using the NEI-VFQ.

METHODS

Participants with AQP4+ NMOSD and MOGAD, 18 years of age and older, were enrolled through the Canadian NMOSD and other atypical demyelinating diseases cohort study (CANOPTICS) at six Canadian centers and consented to enter the patient-reported outcomes sub-study. Participants completed the VFQ at study entry. We compared composite VFQ scores and subscale scores in all participants with NMOSD and MOGAD, those with a history of any ON, and those with a history of bilateral simultaneous ON. We used a multivariable linear regression model to evaluate the association of VFQ composite score with disease type (NMOSD versus MOGAD), age, sex at birth, disease duration, history of unilateral ON, history of bilateral ON, and visual functional system score (FSS).

RESULTS

There were 58 NMOSD participants, 49 (84.5 %) female, mean (SD) age 48.6 (14.8) years, and 42 MOGAD participants, 27 (64.3 %) female, mean (SD) age 45.2(15.1) years. Thirty-five (60.3 %) participants with NMOSD had a history of any ON and 11(19.0 %) of bilateral ON. For MOGAD, 30 (71.4 %) participants had a history of any ON and 14 (33.3 %) of bilateral ON. Mean (SD) VFQ composite scores were 82.2 (17.9) in NMOSD and 83.7 (17.6) in MOGAD for the full cohort; 75.0 (19.9) in NMOSD and 80.4 (18.7) in MOGAD for those with any history of ON; and 70.2 (25.6) in NMOSD and 74.9 (21.8) in MOGAD for bilateral ON. Composite scores did not differ significantly between participants with NMOSD and MOGAD in the full cohort or ON sub-groups. However, history of bilateral ON (β=-13.2, p = 0.0008) and higher visual FSS (β=-4.9, p < 0.0001) were associated with lower VFQ composite scores.

CONCLUSION

In this Canadian multi-center cohort, vision-related quality of life was impaired in both NMOSD and MOGAD, without significant differences observed in scores. Vision-related quality of life assessment offers unique insights into the functional impact of vision loss, and should be considered as an outcome measure to evaluate visual disability in NMOSD and MOGAD in addition to visual acuity.

Comparison of clinical features of aquaporin-4 positive neuromyelitis optica spectrum disorder (NMOSD), myelin oligodendrocyte glycoprotein associated disorder (MOGAD), and double seronegative NMOSD - A single center experience

This retrospective study investigates Aquaporin-4 Antibody Positive Neuromyelitis Optica Spectrum Disorder (NMOSD), Myelin Oligodendrocyte Glycoprotein Associated Disorder (MOGAD), and Seronegative NMOSD at a tertiary care university hospital, over a 13 year period (November 2010 to November 2023) involving 78 patients. It distinguishes between the clinical and radiological features of AQP4 + NMOSD (41 patients, 52.5 %), MOGAD (22 patients, 28.2 %), and Seronegative NMOSD (15 patients, 19.3 %). A significant female majority was noted in AQP4+ NMOSD (90.2 %) compared to MOGAD (45.5 %) and Seronegative NMOSD (66.7 %). Age of disease onset and annualized relapse rates were similar across groups. Myelitis was a common initial symptom in AQP4+ NMOSD (48.8 %) and Seronegative NMOSD (40 %), but less so in MOGAD (18.2 %). Optic neuritis was more frequent in MOGAD (68.2 %) and Seronegative NMOSD (53.3 %) than AQP4+ NMOSD (31.7 %). Relapsing disease was less observed in MOGAD (57.1 %) compared to the other groups. Time to the first relapse varied: 12 months for Seronegative NMOSD, 18 months for AQP4+ NMOSD, and 7 months for MOGAD. A higher incidence of autoimmune disorders was found in AQP4+ NMOSD (36.6 %) versus MOGAD (9.5 %). This study delineates a pronounced female and concurrent autoimmune disorder predominance in AQP4+ NMOSD compared to seronegative NMOSD and MOGAD.

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.

Multiple Sclerosis and Other Acquired Demyelinating Diseases of the Central Nervous System

Acquired demyelinating diseases of the central nervous system (CNS) comprise inflammatory conditions, including multiple sclerosis (MS) and related diseases, as well as noninflammatory conditions caused by toxic, metabolic, infectious, traumatic, and neurodegenerative insults. Here, we review the spectrum of diseases producing acquired CNS demyelination before focusing on the prototypical example of MS, exploring the pathologic mechanisms leading to myelin injury in relapsing and progressive MS and summarizing the mechanisms and modulators of remyelination. We highlight the complex interplay between the immune system, oligodendrocytes and oligodendrocyte progenitor cells (OPCs), and other CNS glia cells such as microglia and astrocytes in the pathogenesis and clinical course of MS. Finally, we review emerging therapeutic strategies that exploit our growing understanding of disease mechanisms to limit progression and promote remyelination.

Retrospective, descriptive study of acute myelitis in French Guyana

BACKGROUND

Acute myelitis is a neurological entity, often posing the problem of etiology. The two main causes are infectious or autoimmune. French Guyana is a region of the world where infectious etiologies are multiple, in particular human immunodeficiency virus infection, and autoimmune diseases appear to be emerging. The aim of our study was firstly to determine the proportion of each etiology of acute myelitis in French Guyana, and secondly to describe the clinical, paraclinical and epidemiological characteristics of autoimmune myelitis in French Guyana, with particular reference to neuromyelitis optica spectrum disorder (NMOSD).

METHODS

This retrospective, observational study included all patients who presented with acute myelitis between January 2015 and August 2023 at Cayenne Hospital Center. Each patient's chart was reviewed and patients were classified according to etiology. Demographic and clinical data were collected, as well as blood, lumbar puncture, and cerebral and spinal cord magnetic resonance imaging results.

RESULTS

Of the 40 patients included, immune etiology was found in 74%, including 49% with NMOSD (37% with positive anti-aquaporin-4 antibodies) compared with three patients with infectious etiology. There was no statistically significant difference in complementary examinations between immune and infectious etiologies. The prevalence of NMOSD in French Guyana was estimated at 8/100,000 (6/100,000 for patients with positive anti-aquaporin-4 antibodies). No significant difference in the geographic distribution of patients with NMOSD in French Guyana was demonstrated.

CONCLUSIONS

Our results show a high proportion of autoimmune etiology of acute myelitis in French Guyana, and more particularly of NMOSD. There is a high prevalence of NMOSD, the second highest in the world after the French West Indies. Given this high proportion of autoimmune myelitis, several hypotheses can be put forward, with genetic and environmental factors in the foreground. For patients with acute myelitis in French Guyana, an immune cause is the most likely. It is therefore important to think about this and look for NMOSD in particular, without ignoring an infectious etiology.

MRI-based radiomics for differention of aquaporin 4-immunoglobulin G-positive neuromyelitis optic spectrum disorder and anti myelin oligodendrocyte glycoprotein immunoglobulin G-associated disorder

OBJECTIVES

This study was designed to develop and validate a radiomic nomogram for the differential diagnosis of myelin oligodendrocyte glycoprotein antibody-related disease (MOGAD) and aquaporin-4 immunoglobulin G-positive neuromyelitis optica spectrum disorder (AQP4+NMOSD).

METHODS

We retrospectively analysed data from a primary cohort consisting of 21 MOGAD and 63 AQP4+NMOSD patients and an external validation cohort comprising 10 MOGAD and 34 AQP4+NMOSD patients. Radiomic features were extracted from lesions of the cervical spinal cord and brainstem from sagittal T2-weighted MR images. We constructed a prediction model by integrating radiomic features with clinical data and evaluated its performance using calibration curves and decision curve analysis (DCA).

RESULTS

We developed a comprehensive nomogram that combines clinical and radiomic features to distinguish MOGAD from AQP4+NMOSD. The discriminative ability of the nomogram was quantified by the area under the receiver operating characteristic (ROC) curve (AUC), achieving values of 0.915 (95 % CI, 0.859-0.970) in the primary cohort and 0.837 (95 % CI, 0.715-0.959) in the validation cohort, indicating high diagnostic accuracy. The calibration analyses showed good concordance between the model predicted and actual outcomes.

CONCLUSIONS

This study successfully validated the radiomic feature model, demonstrating its superior performance in differentiating MOGAD from AQP4+NMOSD. The nomogram, integrating radiomic features with conventional imaging characteristics of brainstem and cervical cord lesions, significantly enhanced differentiation capability. Both models proved valuable in improving diagnostic accuracy, with radiomic features contributing most significantly.

Efficacy of human umbilical cord mesenchymal stem cell in the treatment of neuromyelitis optica spectrum disorders: an animal study

BACKGROUND

Human umbilical cord mesenchymal stem cells (hUC-MSCs) have great potential for treating autoimmune diseases for their immunomodulatory and tissue-regenerative abilities; however, their therapeutic role in neuromyelitis optica spectrum disorder (NMOSD) remains uncertain.

METHODS

106 hUC-MSCs prepared in 200 μl PBS were intravenously administered to a systemic NMOSD model on day 10 and day 14 after immunization. Then, disease progression, immune responses, and blood-brain barrier integrity were evaluated. Additionally, we tested the effects of hUC-MSCs on astrocyte viability and apoptosis using an aquaporin 4 (AQP4) IgG and complement-induced cytotoxicity model in vitro.

RESULTS

hUC-MSCs alleviated NMOSD progression in vivo with improved motor function, reduced inflammatory infiltration, myelin loss, and preservation of astrocytes and neurons. hUC-MSC treatment did not affect autoimmune reactions in the spleen, however, decreased cytokine release in the spinal cord and mitigated blood-brain barrier disruption. Furthermore, in vitro studies revealed that co-culture with hUC-MSCs significantly restored astrocyte viability and reduced apoptosis in AQP4 IgG and complement-mediated damage.

CONCLUSION

Our results revealed that hUC-MSCs displayed therapeutic efficacy in NMOSD and showed potential in attenuating blood-brain barrier disruption, as well as AQP4 IgG and complement-induced astrocyte apoptosis.

Perturbations in gut microbiota composition in patients with autoimmune neurological diseases: a systematic review and meta-analysis

Studies suggest that gut dysbiosis occurs in autoimmune neurological diseases, but a comprehensive synthesis of the evidence is lacking. Our aim was to systematically review and meta-analyze the correlation between the gut microbiota and autoimmune neurological disorders to inform clinical diagnosis and therapeutic intervention. We searched the databases of PubMed, Embase, Web of Science, and the Cochrane Library until 1 March 2024 for research on the correlation between gut microbiota and autoimmune neurological disorders. A total of 62 studies provided data and were included in the analysis (n = 3,126 patients, n = 2,843 healthy individuals). Among the included studies, 42 studies provided data on α-diversity. Regarding α-diversity, except for Chao1, which showed a consistent small decrease (SMD = -0.26, 95% CI = -0.45 to -0.07, p < 0.01), other indices demonstrated no significant changes. While most studies reported significant differences in β-diversity, consistent differences were only observed in neuromyelitis optica spectrum disorders. A decrease in short-chain fatty acid (SCFA)-producing bacteria, including Faecalibacterium and Roseburia, was observed in individuals with autoimmune encephalitis, neuromyelitis optica spectrum disorders, myasthenia gravis, and multiple sclerosis. Conversely, an increase in pathogenic or opportunistic pathogens, including Streptococcus and Escherichia-Shigella, was observed in these patients. Subgroup analyses assessed the confounding effects of geography and immunotherapy use. These findings suggest that disturbances of the gut flora are associated with autoimmune neurological diseases, primarily manifesting as non-specific and shared microbial alterations, including a reduction in SCFA-producing bacteria and an increase in pathogenic or opportunistic pathogens.

Systematic review registration

https://www.crd.york.ac.uk/prospero/, identifier CRD42023410215.

The atypical faces of optic neuritis: neuromyelitis optica spectrum disorder and myelin oligodendrocyte glycoprotein antibody-associated disease

PURPOSE OF REVIEW

The purpose of this article is to provide a review of neuromyelitis optica spectrum disorder (NMOSD) and myelin oligodendrocyte glycoprotein antibody-associated disease (MOGAD), with a focus on what renders optic neuritis "atypical" in these two conditions. Clinical features, diagnostic criteria, and epidemiology are outlined. Acute treatments for optic neuritis, as well as immunotherapy for NMOSD and MOGAD are discussed.

RECENT FINDINGS

Updates in NMOSD and MOGAD are highlighted, with an emphasis on novel work including the new 2023 MOGAD diagnostic criteria, our evolving understanding on the epidemiology of these conditions, and recently FDA-approved NMOSD treatments. Pipeline therapies are also discussed.

SUMMARY

A thorough history and examination, supported by ancillary testing, continues to be the mainstay of optic neuritis diagnosis. Stratifying typical versus atypical optic neuritis is paramount. Within the atypical category, NMOSD and MOGAD are important considerations. Clues can point towards these diagnoses and guide steps for treatment, which is increasingly becoming targeted to individual diseases, as the pathophysiology is different for these disorders.

A Case Report of Neuromyelitis Optica Spectrum Disorder (NMOSD) Treatment in Resource-Limited Setup: An Ethiopian Experience

MOSD is a rare and disabling immune-mediated inflammatory Astrocytopathic disease characterized by demyelination and axonal destruction, typically involving the spinal cord and the optic nerve. Here we present a case report of a 53-year-old female patient who had a pertinent history of treatment for optic neuritis a few months back, currently diagnosed with Neuromyelitis Optica after she presented with a three-week history of weakness of lower extremity, headache, and neuropathic pain. She was pulsed with methylprednisolone and started on azathioprine, which significantly improved her clinical condition. When patients with optic neuritis and transverse myelitis occur, a high index of suspicion for NMOSD is essential. Establishing a diagnosis based on clinical and MRI findings is crucial for initiating therapy quickly, halting more harm, and avoiding a delay in diagnosis. Our experience treating our patient shows that Azathioprine is still a practical choice in resource-limited setups.

Novel Automated Chemiluminescent Immunoassay for the Detection of Autoantibodies Against Aquaporin-4 in Neuromyelitis Optica Spectrum Disorders

Background/Objectives: Neuromyelitis optica spectrum disorder (NMOSD) is an autoimmune-related neurological disease that primarily affects the optic nerve and spinal cord. According to current international consensus guidelines for NMOSD, confirming the presence of aquaporin-4 immunoglobulin G antibody (AQP4-IgG) is one of the most important diagnostic criteria because AQP4-IgG is a significant diagnostic biomarker of NMOSD. Several assays are currently available for detecting AQP4-IgG, including cell-based assays (CBAs) and enzyme-linked immunosorbent assays (ELISAs). However, each assay has certain disadvantages, including insufficient sensitivity and specificity, the need for sophisticated techniques, and semi-quantitative results. Methods: We developed a fully automated chemiluminescent enzyme immunoassay (CLEIA) to detect AQP4-IgG (AQP4-CLEIA). This assay utilizes the recombinant antigen purified from the newly generated AQP4-M23 stably expressing Chinese hamster ovary cell line and an anti-AQP4 monoclonal antibody as a calibrator. Results: In analytical performance studies, the assay demonstrates good precision and linearity over the entire measurement range. Moreover, this assay showed no high-dose hook effect and interference from endogenous substances. In clinical validation studies, patients with AQP4-IgG positive NMOSD, multiple sclerosis, or myelin oligodendrocyte glycoprotein antibody-associated disorder and healthy individuals were tested. A cutoff value of 10.0 U/mL was determined by receiver operating characteristic curves based on the results of a microscopic live CBA. The sensitivity and specificity for AQP4-IgG-positive NMOSD were 97.0% and 100.0%, respectively, at the cutoff value. Conclusions: The results suggest that AQP4-CLEIA is a convenient automated method for measuring AQP4-IgG titers in hospitals and clinical laboratories, offering an effective alternative to the gold-standard CBA.

Distinct clinical patterns in AQP4-IgG- positive NMOSD patients vs. Seronegative: Insights from a single-center study in Argentina

BACKGROUND

Distinct clinical course patterns have been identified between AQP4-IgG-positive and AQP4-IgG-negative NMOSD patients.

OBJECTIVES

This study aimed to evaluate the differences between AQP4-IgG-seropositive and AQP4-IgG-seronegative NMOSD patients in a single centre in Argentina.

METHODS

We performed a retrospective cross-sectional study of 108 NMOSD patients in the city of Buenos Aires, Argentina.

RESULTS

We selected 94 for analysis. 77 patients (82 %) were AQP4-IgG positive. In the AQP4-IgG positive group, the ratio of male to female was 1:10 vs. 1:1.2 in the seronegative group (p = 0.001). Relapses were observed in 76 out of 77 (99 %) AQP4-IgG positive patients versus 3 out of 17 (17.6 %) AQP4-IgG negative patients (p = 0.01). In the seropositive group, other autoimmune diseases were present in 34/77 patients (44 %) vs. 2/12 (12 %) in the seronegative patients, a statistically significant difference (p = 0.009). 81 % of the seropositive group had an early adulthood onset (EAO-NMOSD) compared to 35 % in the seronegative group. All AQP4+ patients positive received treatment with monoclonal antibodies. In AQP4-IgG- NMOSD patients the use of immunosuppressive treatment was more common.

CONCLUSION

Female predominance, EAO-NMOSD, recurrence course and a high prevalence of autoimmune disease in AQP4-IgG-positive patients demonstrated a more pronounced autoimmunity profile.

Breaking New Ground: A Seropositive Neuromyelitis Optica (NMOSD) in Ethiopian Patients: A Case Series

This case series highlights the diverse presentations of seropositive neuromyelitis optica spectrum disorder, including the absence of optic neuritis despite anti-aquaporin 4 antibody positivity. It emphasizes the importance of high index of suspicion, early neurologist referral for improved outcomes, the consequences of delayed referral, and the challenges and treatment potential in low-income countries with limited resources.

The epidemiology and clinical presentation of seropositive neuromyelitis optica spectrum disorder in a US population

OBJECTIVE

To define the epidemiology and clinical presentation of seropositive neuromyelitis optica spectrum disorder (NMOSD) in a large US health system.

METHODS

We completed a retrospective observational study of adult patients in the University of Colorado Health System from 1 January 2011 to 31 December 2020, using Health Data Compass (HDC), a data warehouse that combines electronic health information with claims and public health data in Colorado. We screened HDC for patients with either (1) an abnormal aquaporin-4 IgG test or (2) any G36 ICD-10 code. We extracted key clinical elements by chart review and confirmed diagnosis by the 2015 International Panel for NMO Diagnosis criteria. Annual incidence and prevalence rates were calculated.

RESULTS

Our population consisted of 2,475,591 individuals contributing 11,103,522.72 person-years of observation. In total, 115 seropositive NMOSD patients were identified. The average yearly incidence was 0.22 per 100,000 person-years. Age and sex-adjusted prevalence (per 100,000) was 4.33, and highest among those identifying as Asian or Pacific Islander (17.72), and Black (14.74), as separately by Hispanic ethnicity (8.02). Prevalence was higher in women (6.20:1 female:male ratio). Transverse myelitis (45%) and optic neuritis (43%) were the most common presenting clinical syndromes. In total, 6% of initial presentations were characterized by short-segment transverse myelitis without other features.

INTERPRETATION

Seropositive NMOSD incidence is higher in our cohort than many contemporary studies. Women and those identifying as Asian or Pacific Islander, Black, and Hispanic shoulder the highest burden of disease. Clinical onset with short-segment myelitis underscores the need for serum aquaporin-4 IgG testing in acute myelitis presentations.

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.

Relapse risk factors analysis within 1 year after the first onset of neuromyelitis optica spectrum disorders: A two-center retrospective study

BACKGROUND

Neuromyelitis optica spectrum disorders (NMOSD) is a highly relapsing and disabling disease that causes severe neurological dysfunction in young patients and often has a poor prognosis. Our study aimed to investigate risk factors affecting NMOSD relapse and to establish a relapse prediction model within 1 year after the first onset, providing a reference for individualized diagnosis and treatment of NMOSD patients.

METHODS

We retrospectively analyzed clinical data of 102 NMOSD patients admitted to the Second Affiliated Hospital of Soochow University and the Second People's Hospital of Wuxi from January 2020 to August 2023 at their initial presentation. Patients were divided into relapse and non-relapse groups based on the occurrence of relapse within 1 year post-diagnosis. Clinical data were compared between groups, and the relationship between each factor and disease relapse was assessed using single-factor analysis. Binary logistic regression analysis was applied to identify independent risk factors for relapse within 1 year after the first onset of NMOSD, and a Nomogram relapse prediction model was developed and validated.

RESULTS

Significant differences were observed in NLR, B lymphocyte level, NK cell count, immunosuppressant use, EDSS score, and spinal lesion segment length between the relapsed and non-relapsed groups (P < 0.05). Binary logistic regression analysis revealed that NLR, B lymphocyte level, NK cell count, non-use of immunosuppressants, and EDSS score were independent risk factors for relapse within 1 year after the first onset of NMOSD. NLR, B lymphocyte level, and EDSS score were positively correlated with the risk of disease relapse, while NK cell count was negatively correlated. A Nomogram prediction model was constructed based on these independent risk factors. The model's C index was 0.788 (95 % CI: 0.698-0.878, P = 0.000), indicating good discrimination. The Bootstrap-corrected C index was 0.787, suggesting robust calibration. Decision curve analysis confirmed the model's clinical utility.

CONCLUSIONS

Peripheral blood NLR, B lymphocyte level, NK cell count, non-use of immunosuppressants, and EDSS score are risk factors for NMOSD relapse within 1 year after the first onset and can serve as predictive indicators. Early identification of the high-risk relapse group is crucial for the individualized management of NMOSD patients.

Pediatric Neuroimaging of Multiple Sclerosis and Neuroinflammatory Diseases

Using a pediatric-focused lens, this review article briefly summarizes the presentation of several demyelinating and neuroinflammatory diseases using conventional magnetic resonance imaging (MRI) sequences, such as T1-weighted with and without an exogenous gadolinium-based contrast agent, T2-weighted, and fluid-attenuated inversion recovery (FLAIR). These conventional sequences exploit the intrinsic properties of tissue to provide a distinct signal contrast that is useful for evaluating disease features and monitoring treatment responses in patients by characterizing lesion involvement in the central nervous system and tracking temporal features with blood-brain barrier disruption. Illustrative examples are presented for pediatric-onset multiple sclerosis and neuroinflammatory diseases. This work also highlights findings from advanced MRI techniques, often infrequently employed due to the challenges involved in acquisition, post-processing, and interpretation, and identifies the need for future studies to extract the unique information, such as alterations in neurochemistry, disruptions of structural organization, or atypical functional connectivity, that may be relevant for the diagnosis and management of disease.

HLA-transgenic mouse models to study autoimmune central nervous system diseases

It is known that certain human leukocyte antigen (HLA) genes are associated with autoimmune central nervous system (CNS) diseases, such as multiple sclerosis (MS), but their exact role in disease susceptibility and etiopathogenesis remains unclear. The best studied HLA-associated autoimmune CNS disease is MS, and thus will be the primary focus of this review. Other HLA-associated autoimmune CNS diseases, such as autoimmune encephalitis and neuromyelitis optica will be discussed. The lack of animal models to accurately capture the complex human autoimmune response remains a major challenge. HLA transgenic (tg) mice provide researchers with powerful tools to investigate the underlying mechanisms promoting susceptibility and progression of HLA-associated autoimmune CNS diseases, as well as for elucidating the myelin epitopes potentially targeted by T cells in autoimmune disease patients. We will discuss the potential role(s) of autoimmune disease-associated HLA alleles in autoimmune CNS diseases and highlight information provided by studies using HLA tg mice to investigate the underlying pathological mechanisms and opportunities to use these models for development of novel therapies.

Rituximab maintenance treatment outcomes in patients with relapsing neuromyelitis optica spectrum disorder: a monocentric retrospective analysis

Some patients with neuromyelitis optica spectrum disorder (NMOSD) experience relapse after rituximab (RTX) treatment. In this retrospective study, we analyzed the recurrence-related clinical features, laboratory investigation results, and dosing protocol of 30 female patients with relapsing NMOSD with immunoglobulin G autoantibodies against aquaporin-4 and relapses during repeated 0.5 g RTX infusions as maintenance treatment. The median follow-up period was 6.62 years. Thirty-five episodes were observed, with myelitis being the most frequent. The median expanded disability status scale change score was 0.50. The recurrence rate decreased by 44.23%/year with RTX infusion. Approximately 85.71% of the patients showed relapse without RTX infusion within 10 months. Overall, RTX may be effective for relapsing NMOSD cases.

Immunosuppressive therapy in elderly patients with neuromyelitis optica spectrum disorder: a retrospective multicentre study

BACKGROUND

The risk-benefit relationship of immunosuppressive therapies (ISTs) for elderly patients with neuromyelitis optica spectrum disorder (NMOSD) is not well established. This study aimed to investigate the safety and efficacy of IST in elderly patients with NMOSD.

METHODS

This retrospective study analysed IST efficacy and safety in 101 patients with aquaporin-4 antibody-positive NMOSD aged over 65 years, treated for at least 6 months at five Korean referral centres, focusing on relapse rates, infection events and discontinuation due to adverse outcomes.

RESULTS

The mean age at disease onset was 59.8 years, and female-to-male ratio was 4:1. Concomitant comorbidities at NMOSD diagnosis were found in 87 patients (86%). The median Expanded Disability Status Scale score at the initiation of IST was 3.5. The administered ISTs included azathioprine (n=61, 60%), mycophenolate mofetil (MMF) (n=48, 48%) and rituximab (n=41, 41%). Over a median of 5.8 years of IST, 58% of patients were relapse-free. The median annualised relapse rate decreased from 0.76 to 0 (p<0.001), and 81% experienced improved or stabilised disability. Patients treated with rituximab had a higher relapse-free rate than those treated with azathioprine or MMF (p=0.022). During IST, 21 patients experienced 25 severe infection events (SIEs) over the age of 65 years, and 3 died from pneumonia. 14 patients (14%) experienced 17 adverse events that led to switching or discontinuation of IST. When comparing the incidence rates of SIEs and adverse events, no differences were observed among patients receiving azathioprine, MMF and rituximab.

CONCLUSION

In elderly patients with NMOSD, IST offers potential benefits in reducing relapse rates alongside a tolerable risk of adverse events.

Neuromyelitis optica spectrum disorder with ultra-longitudinally extensive transverse myelitis: A case report and literature review

Background

Neuromyelitis optica spectrum disorders (NMOSD) is characterized by inflammatory demyelinating events in the central nervous system (CNS), primarily affecting the spinal cord and optic nerve, with a significant influence of astrocytes. Longitudinal extensive transverse myelitis (LETM) is a distinct and relatively rare spinal cord syndrome, commonly associated with NMOSD.

Case presentation

This report describes a unique case of myelitis in a patient diagnosed with NMOSD. The patient exhibited an uncommon manifestation of ultra- LETM (u-LETM), coexisting with connective tissue disorders including Sjögren's syndrome and autoimmune hepatitis-primary cholestatic cirrhosis. In the acute phase, high-dose methylprednisolone pulse therapy was administered in combination with intravenous human immunoglobulin, while prednisone was gradually tapered and discontinued upon stabilization of the patient's condition. Simultaneously, sequential disease-modifying therapy was initiated, starting with long-term oral administration of mycophenolate mofetil, followed by cyclophosphamide, telitacicept, and Inebilizumab. During follow-up visits conducted every three months, the patient showed gradual improvement, eventually achieving the ability to stand and walk independently.

Conclusions

Early and comprehensive evaluation of autoimmune diseases is crucial in patients with NMOSD presenting with u-LETM as the initial symptom. Prompt treatment initiation, followed by disease-modifying therapy, is essential for improving patient prognosis.

Spectrum of Auto-antibodies in NMO and MOG Associated CNS Demyelination- The SANMAD Study

This observational study explored coexisting organ-specific and non-organ-specific autoantibodies in Neuromyelitis optica spectrum disorder(NMOSD) and Myelin oligodendrocyte glycoprotein-IgG-1(MOG-IgG1) associated central nervous system demyelination(MOGAD) in a South Asian cohort from March 2017-2023. Of the 250 cases, 148 were MOGAD(82pediatric) and 102 were NMOSD(15 pediatric). 17.6 % tested positive for ≥1 antibody, with NMOSD showing a higher positivity rate (25.5 %) than MOGAD(12.2 %,p = 0.011). Double antibody positivity occurred more in NMOSD (5.9 %vs.MOGAD,1.4 %,p = 0.045). Three NMOSD cases had Sjogren syndrome with higher Anti-Ro-52 prevalence(12.7 %vs.4.1 %,p = 0.014). NMOSD patients with ≥1 antibody positivity had more constitutional symptoms (45.5 %vs.23.1 %,p = 0.045). Significant associations were found between NMOSD and female gender, having ≥1 antibody-positive status, and testing positive for Anti-Ro-52 and SS-A antibodies (p < 0.05).

Effects of early intervention in neuromyelitis optica spectrum disorder patients with seropositive AQP4 antibodies

Background

The impact of early intervention with immunosuppressive treatment (IST) in anti-Aquaporin4-antibody (AQP4-ab) seropositive neuromyelitis optica spectrum disorder (NMOSD) has not been thoroughly evaluated.

Objective

This study aims to assess the effects of early IST intervention in patients with NMOSD.

Methods

This retrospective cohort study included 174 treatments from 137 NMOSD patients seropositive for AQP4-antibody, treated with ISTs such as rituximab, mycophenolate mofetil, azathioprine, or tacrolimus. Multiple statistical analyses, including regression discontinuity design (RDD), kaplan-meier analyze, Cox proportional hazards regression model, were employed to evaluate the effects of early IST intervention on annualized relapse rate (ARR) change, Expanded Disability Status Scale (EDSS) change, and time to next relapse.

Results

A total of 174 treatments from 137 patients were analyzed. Patients exhibited significant improvement in ARR[1.95 vs.0, IQR (0.70-6.0 vs. 0-0.42), p<0.001] and EDSS [3.0 vs. 2.5, IQR (2.0-4.0 vs. 1.0-3.0) p<0.001]after IST, although the ARR change was not significant in patients treated with TAC. Early IST initiation was associated with greater improvements in both ARR and EDSS compared to later initiation. RDD analysis demonstrated a time-dependent effect of ARR-change, indicating greater efficacy with early IST intervention.

Conclusions

Early intervention with ISTs in AQP4-antibody-positive NMOSD patients is associated with better outcomes in terms of reducing relapse rate and improving disability. These findings underscore the importance of early treatment in NMOSD.

Optical coherence tomography angiography of the retina and choroid in systemic diseases

Optical coherence tomography angiography (OCTA) has transformed ocular vascular imaging, revealing microvascular changes linked to various systemic diseases. This review explores its applications in diabetes, hypertension, cardiovascular diseases, and neurodegenerative diseases. While OCTA provides a valuable window into the body's microvasculature, interpreting the findings can be complex. Additionally, challenges exist due to the relative non-specificity of its findings where changes observed in OCTA might not be unique to a specific disease, variations between OCTA machines, the lack of a standardized normative database for comparison, and potential image artifacts. Despite these limitations, OCTA holds immense potential for the future. The review highlights promising advancements like quantitative analysis of OCTA images, integration of artificial intelligence for faster and more accurate interpretation, and multi-modal imaging combining OCTA with other techniques for a more comprehensive characterization of the ocular vasculature. Furthermore, OCTA's potential future role in personalized medicine, enabling tailored treatment plans based on individual OCTA findings, community screening programs for early disease detection, and longitudinal studies tracking disease progression over time is also discussed. In conclusion, OCTA presents a significant opportunity to improve our understanding and management of systemic diseases. Addressing current limitations and pursuing these exciting future directions can solidify OCTA as an indispensable tool for diagnosis, monitoring disease progression, and potentially guiding treatment decisions across various systemic health conditions.

Integrated omics profiling reveals systemic dysregulation and potential biomarkers in the blood of patients with neuromyelitis optica spectrum disorders

BACKGROUND

Neuromyelitis optica spectrum disorders (NMOSD) are autoimmune conditions that affect the central nervous system. The contribution of peripheral abnormalities to the disease's pathogenesis is not well understood.

METHODS

To investigate this, we employed a multi-omics approach analyzing blood samples from 52 NMOSD patients and 46 healthy controls (HC). This included mass cytometry, cytokine arrays, and targeted metabolomics. We then analyzed the peripheral changes of NMOSD, and features related to NMOSD's disease severity. Furthermore, an integrative analysis was conducted to identify the distinguishing characteristics of NMOSD from HC. Additionally, we unveiled the variations in peripheral features among different clinical subgroups within NMOSD. An independent cohort of 40 individuals with NMOSD was utilized to assess the serum levels of fibroblast activation protein alpha (FAP).

RESULTS

Our analysis revealed a distinct peripheral immune and metabolic signature in NMOSD patients. This signature is characterized by an increase in monocytes and a decrease in regulatory T cells, dendritic cells, natural killer cells, and various T cell subsets. Additionally, we found elevated levels of inflammatory cytokines and reduced levels of tissue-repair cytokines. Metabolic changes were also evident, with higher levels of bile acids, lactates, triglycerides, and lower levels of dehydroepiandrosterone sulfate, homoarginine, octadecadienoic acid (FA[18:2]), and sphingolipids. We identified distinctive biomarkers differentiating NMOSD from HC and found blood factors correlating with disease severity. Among these, fibroblast activation protein alpha (FAP) was a notable marker of disease progression.

CONCLUSIONS

Our comprehensive blood profile analysis offers new insights into NMOSD pathophysiology, revealing significant peripheral immune and metabolic alterations. This work lays the groundwork for future biomarker identification and mechanistic studies in NMOSD, highlighting the potential of FAP as a marker of disease progression.

First-in-Human Study of BAT4406F, an ADCC-Enhanced Fully Humanized Anti-CD20 Monoclonal Antibody in Patients With Neuromyelitis Optica Spectrum Disorders

INTRODUCTION

Neuromyelitis optica spectrum disorder (NMOSD) is a rare debilitating autoimmune disease of the central nervous system (CNS). This is the first-in-human dose-escalation Phase I clinical study of BAT4406F, an antibody-dependent cell-mediated cytotoxicity (ADCC)-enhanced fully humanized anti-CD20 monoclonal antibody, in Chinese NMOSD patients.

PATIENTS AND METHODS

Using a "3 + 3" design and based on the planned algorithm of dose escalation, the enrolled NMOSD patients were sequentially assigned to one of the five dose-escalation cohorts of BAT4406F with a single intravenous dose, and were then followed for a 6-month observation period. The maximum tolerated dose (MTD) and dose-limiting toxicity (DLT), safety, pharmacokinetics (PK), pharmacodynamics, and immunogenicity of BAT4406F were investigated, and the efficacy of BAT4406F in NMOSD was also preliminarily explored.

RESULTS

Fifteen Chinese NMOSD patients were enrolled to receive BAT4406F of escalated doses ranging from 20 to 750 mg. No subjects experienced DLT at the studied doses. BAT4406F injection exhibited favorable safety, with most of the adverse events (AE) of CTCAE Grade 1 or 2 in severity, and no Grade ≥ 3 adverse drug reactions (ADR) or serious adverse reactions occurred in any subjects. With the dose increase of BAT4406F, the maximum plasma concentration (Cmax), area under concentration-time curve from 0 to the last measurable timepoint (AUC0-t) and area under concentration-time curve from 0 to infinity (AUC0-inf) showed an increasing trend, whereas the mean clearance (CLt), terminal elimination rate (λZ), and apparent volume of distribution (Vd) decreased. The mean elimination half-life (T1/2) was ranged from 9.0-16.4 days. PK profile of BAT4406F was generally nonlinear. BAT4406F led to a rapid and significant B-cell depletion in all dose groups. Single administration of 500 mg or 750 mg maintains the CD19+ B lymphocyte count below 10/μL within the whole 6-month observation period. Three subjects were antidrug antibody (ADA) positive and all of them were neutralizing antibody (NAb)-negative. On day 99/180 postdose, several groups had decreased expanded disability status scale (EDSS) scores compared to baseline. During the observation period, NMOSD relapse occurred in two patients (13.3%) and the other 13 (86.7%) subjects remained relapse free.

CONCLUSION

BAT4406F was well tolerated at doses up to 750 mg and showed an expected pharmacodynamic effect of significant and long-term depletion of CD19+ B lymphocytes. It has also shown preliminary evidence of activity in NMOSD maintenance treatment, warranting further investigations.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT04146285.

Artificial intelligence in healthcare: a mastery

There is a vast development of artificial intelligence (AI) in recent years. Computational technology, digitized data collection and enormous advancement in this field have allowed AI applications to penetrate the core human area of specialization. In this review article, we describe current progress achieved in the AI field highlighting constraints on smooth development in the field of medical AI sector, with discussion of its implementation in healthcare from a commercial, regulatory and sociological standpoint. Utilizing sizable multidimensional biological datasets that contain individual heterogeneity in genomes, functionality and milieu, precision medicine strives to create and optimize approaches for diagnosis, treatment methods and assessment. With the arise of complexity and expansion of data in the health-care industry, AI can be applied more frequently. The main application categories include indications for diagnosis and therapy, patient involvement and commitment and administrative tasks. There has recently been a sharp rise in interest in medical AI applications due to developments in AI software and technology, particularly in deep learning algorithms and in artificial neural network (ANN). In this overview, we enlisted the major categories of issues that AI systems are ideally equipped to resolve followed by clinical diagnostic tasks. It also includes a discussion of the future potential of AI, particularly for risk prediction in complex diseases, and the difficulties, constraints and biases that must be meticulously addressed for the effective delivery of AI in the health-care sector.

Dried blood spot improves global access to aquaporin-4-IgG testing for neuromyelitis optica

OBJECTIVE

This study aimed to evaluate the diagnostic accuracy of dried blood spot (DBS) compared with conventional serum Aquaporin-4-IgG (AQP4-IgG) testing.

METHODS

Prospective multicenter diagnostic study was conducted between April 2018 and October 2023 across medical centers in the United States, Uganda, and the Republic of Guinea. Neuromyelitis optica spectrum disorder (NMOSD) patients and controls collected blood on filter paper cards along with concurrent serum samples. These samples underwent analysis using flow cytometric live-cell-based assays (CBA) and enzyme-linked immunosorbent assay (ELISA) to determine AQP4 serostatus. The accuracy of AQP4-IgG detection between DBS and serum (gold standard) was compared.

RESULTS

Among 150 participants (47 cases, 103 controls), there was a strong correlation between DBS and serum samples (Spearman's correlation coefficient of 0.82). The AUC was 0.97 (95% CI: 0.92-0.99). AQP4-IgG detection through DBS showed 87.0% sensitivity (95% CI: 0.74-0.95) and 100% specificity (95% CI: 0.96-1.00) using CBA, and 65.2% sensitivity (95% CI: 0.43-0.84) and 95.2% specificity (95% CI: 0.76-0.99) using ELISA. Serum ELISA demonstrated 69.6% sensitivity (95% CI: 0.47-0.87) and 98.4% specificity (95% CI: 0.91-0.99). The stability of DBS in detecting AQP4-IgG persisted over 24 months for most cases.

INTERPRETATION

The DBS represents a viable alternative for detecting AQP4-IgG in resource-limited settings to diagnose NMOSD, offering high sensitivity and specificity comparable to serum testing. Moreover, DBS has low shipping costs, is easy to administer, and is suitable for point-of-care testing.

Differential diagnosis of suspected multiple sclerosis: global health considerations

The differential diagnosis of multiple sclerosis can present specific challenges in patients from Latin America, Africa, the Middle East, eastern Europe, southeast Asia, and the Western Pacific. In these areas, environmental factors, genetic background, and access to medical care can differ substantially from those in North America and western Europe, where multiple sclerosis is most common. Furthermore, multiple sclerosis diagnostic criteria have been developed primarily using data from North America and western Europe. Although some diagnoses mistaken for multiple sclerosis are common regardless of location, a comprehensive approach to the differential diagnosis of multiple sclerosis in Latin America, Africa, the Middle East, eastern Europe, southeast Asia, and the Western Pacific regions requires special consideration of diseases that are prevalent in those locations. A collaborative effort has therefore assessed global differences in multiple sclerosis differential diagnoses and proposed recommendations for evaluating patients with suspected multiple sclerosis in regions beyond North America and western Europe.

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.

Application of the international criteria for optic neuritis in the Acute Optic Neuritis Network

OBJECTIVE

The first international consensus criteria for optic neuritis (ICON) were published in 2022. We applied these criteria to a prospective, global observational study of acute optic neuritis (ON).

METHODS

We included 160 patients with a first-ever acute ON suggestive of a demyelinating CNS disease from the Acute Optic Neuritis Network (ACON). We applied the 2022 ICON to all participants and subsequently adjusted the ICON by replacing a missing relative afferent pupillary defect (RAPD) or dyschromatopsia if magnetic resonance imaging pathology of the optical nerve plus optical coherence tomography abnormalities or certain biomarkers are present.

RESULTS

According to the 2022 ICON, 80 (50%) patients were classified as definite ON, 12 (7%) patients were classified as possible ON, and 68 (43%) as not ON (NON). The main reasons for classification as NON were absent RAPD (52 patients, 76%) or dyschromatopsia (49 patients, 72%). Distribution of underlying ON etiologies was as follows: 78 (49%) patients had a single isolated ON, 41 (26%) patients were diagnosed with multiple sclerosis, 25 (16%) patients with myelin oligodendrocyte glycoprotein antibody-associated disease, and 15 (9%) with neuromyelitis optica spectrum disorder. The application of the adjusted ON criteria yielded a higher proportion of patients classified as ON (126 patients, 79%).

INTERPRETATION

According to the 2022 ICON, almost half of the included patients in ACON did not fulfill the requirements for classification of definite or possible ON, particularly due to missing RAPD and dyschromatopsia. Thorough RAPD examination and formal color vision testing are critical to the application of the 2022 ICON.

Cytomegalovirus and Epstein-Barr virus infections in patients with neuromyelitis optica spectrum disorder

OBJECTIVES

Cytomegalovirus (CMV) and Epstein-Barr virus (EBV) infections in patients with Neuromyelitis optica spectrum disorder (NMOSD) remain unclear. The objective of this study was to investigate CMV and EBV infections in patients with NMOSD.

METHODS

Serum immunoglobin (Ig) G antibodies against CMV and EBV were measured in patients with NMOSD and healthy controls (HCs), including anti-CMV, anti-EBV nuclear antigen-1 (EBNA-1), anti-EBV virus capsid antigen (VCA), and anti-EBV early antigen (EA) IgGs. The immune status ratio (ISR) was used to evaluate the serum anti-CMV and anti-EBV IgG levels and ISR ≧1.10 was defined as seropositivity.

RESULTS

In total, 238 serum samples were collected from 94 patients with NMOSD and 144 HCs, and no significant difference of sex and age between NMOSD and HCs. Comparing to the HCs, patients with NMOSD exhibited significantly higher serum anti-CMV IgG level. In contrast, the serum anti-EBNA1 IgG level was significantly lower in patients with NMOSD than in HCs. The serum anti-VCA and anti-EA IgG levels did not differ between the two groups, but the anti-EA seropositivity was significantly higher in NMOSD group than that in HC group. We did not find associations between serum anti-CMV or anti-EBV IgG levels and NMOSD disease stage, immunotherapy, or disability score.

CONCLUSIONS

Our findings indicated that increased CMV infection and EBV recent infection, as well as reduced EBV latency infection were associated with the risk of NMOSD. Prospective cohort studies are needed to verify our findings and clarify the correlation between CMV and EBV infections and clinical characteristics of NMOSD.

Visual improvement in a case of neuromyelitis optica spectrum disorder-related optic neuritis after 18 months of treatment with satralizumab: A case report

Neuromyelitis optica spectrum disorder-related optic neuritis (NMOSD-ON) is an autoimmune disease that affects the astrocytes. NMOSD-ON is one of the core clinical phenotypes of neuromyelitis optica spectrum disorder and its most-common initial symptom. NMOSD-ON is characterized by severe vision loss, poor prognosis and high recurrence, mainly affecting young and middle-aged individuals. It is a challenge to know how to improve patients' visual outcomes. In this report, we present a refractory case of NMOSD-ON treated with satralizumab after multiple conventional therapies proved ineffective. Satralizumab was found to effectively control relapses in this patient and visual improvement was found after 18 months of treatment. Given to that, satralizumab may have a potential longitudinal effect on visual improvement in NMOSD-ON.

NMOSD and MOGAD

OBJECTIVE

This article reviews the clinical features, MRI characteristics, diagnosis, and treatment of aquaporin-4 antibody-positive neuromyelitis optica spectrum disorder (AQP4-NMOSD) and myelin oligodendrocyte glycoprotein antibody-associated disease (MOGAD). The main differences between these disorders and multiple sclerosis (MS), the most common demyelinating disease of the central nervous system (CNS), are also highlighted.

LATEST DEVELOPMENTS

The past 20 years have seen important advances in understanding rare demyelinating CNS disorders associated with AQP4 IgG and myelin oligodendrocyte glycoprotein (MOG) IgG. The rapidly expanding repertoire of immunosuppressive agents approved for the treatment of AQP4-NMOSD and emerging as potentially beneficial in MOGAD mandates prompt recognition of these diseases. Most of the recent literature has focused on the identification of clinical and MRI features that help distinguish these diseases from each other and MS, simultaneously highlighting major diagnostic pitfalls that may lead to misdiagnosis. An awareness of the limitations of currently available assays for AQP4 IgG and MOG IgG detection is fundamental for identifying rare false antibody positivity and avoiding inappropriate treatments. For this purpose, diagnostic criteria have been created to help the clinician interpret antibody testing results and recognize the clinical and MRI phenotypes associated with AQP4-NMOSD and MOGAD.

ESSENTIAL POINTS

An awareness of the specific clinical and MRI features associated with AQP4-NMOSD and MOGAD and the limitations of currently available antibody testing assays is crucial for a correct diagnosis and differentiation from MS. The growing availability of effective treatment options will lead to personalized therapies and improved outcomes.

Serum LDL Promotes Microglial Activation and Exacerbates Demyelinating Injury in Neuromyelitis Optica Spectrum Disorder

Neuromyelitis optica spectrum disorder (NMOSD) is an autoimmune inflammatory demyelinating disease of the central nervous system (CNS) accompanied by blood-brain barrier (BBB) disruption. Dysfunction in microglial lipid metabolism is believed to be closely associated with the neuropathology of NMOSD. However, there is limited evidence on the functional relevance of circulating lipids in CNS demyelination, cellular metabolism, and microglial function. Here, we found that serum low-density lipoprotein (LDL) was positively correlated with markers of neurological damage in NMOSD patients. In addition, we demonstrated in a mouse model of NMOSD that LDL penetrates the CNS through the leaky BBB, directly activating microglia. This activation leads to excessive phagocytosis of myelin debris, inhibition of lipid metabolism, and increased glycolysis, ultimately exacerbating myelin damage. We also found that therapeutic interventions aimed at reducing circulating LDL effectively reversed the lipid metabolic dysfunction in microglia and mitigated the demyelinating injury in NMOSD. These findings shed light on the molecular and cellular mechanisms underlying the positive correlation between serum LDL and neurological damage, highlighting the potential therapeutic target for lowering circulating lipids to alleviate the acute demyelinating injury in NMOSD.

Preferences for neuromyelitis optica spectrum disorder treatments: A conjoint analysis with neurologists in Spain

BACKGROUND

The treatment landscape for neuromyelitis optica spectrum disorder (NMOSD) has changed in recent years with the approval of therapies with different efficacy, safety and administration profiles.

OBJECTIVE

The aim of this study was to assess neurologists' preferences for different NMOSD treatment attributes using conjoint analysis (CA).

METHODS

We conducted an online, non-interventional, cross-sectional study in collaboration with the Spanish Society of Neurology. Our CA assessed five drugs' attributes: prevention of relapse, prevention of disability accumulation, safety risk, management during pregnancy, and route and frequency of administration. Participants were presented with eight hypothetical treatment scenarios to rank based on their preferences from the most preferred to the least. An ordinary least squares method was selected to estimate weighted preferences.

RESULTS

A total of 104 neurologists were included. Mean age (standard deviation-SD) was 37.7 (10.3) years, 52.9 % were male, and median time (interquartile range) of experience managing NMOSD was 5.0 (2.9, 10.8) years. Neurologists placed the greatest importance on efficacy attributes, time to relapse (44.1 %) being the most important, followed by preventing disability accumulation (36.8 %). In contrast, route and frequency of administration (4.6 %) was the least important characteristic. Participants who prioritised efficacy attributes felt more comfortable in decision-making, had fewer past experiences of care-related regret and a lower attitude to risk taking than their counterparts.

CONCLUSION

Neurologists' treatment preferences in NMOSD were mainly driven by efficacy attributes. These results may be useful to design policy decisions and treatment guidelines for this condition.

Moving towards a new era for the treatment of neuromyelitis optica spectrum disorders

Neuromyelitis optica spectrum disorders (NMOSD) include a rare group of autoimmune conditions that primarily affect the central nervous system. They are characterized by inflammation and damage to the optic nerves, brain and spinal cord, leading to severe vision impairment, locomotor disability and sphynteric disturbances. In the majority of cases, NMOSD arises due to specific serum immunoglobulin G (IgG) autoantibodies targeting aquaporin 4 (AQP4-IgG), which is the most prevalent water-channel protein of the central nervous system. Early diagnosis and treatment are crucial to manage symptoms and prevent long-term disability in NMOSD patients. NMOSD were previously associated with a poor prognosis. However, recently, a number of randomized controlled trials have demonstrated that biological therapies acting on key elements of NMOSD pathogenesis, such as B cells, interleukin-6 (IL-6) pathway, and complement, have impressive efficacy in preventing the occurrence of clinical relapses. The approval of the initial drugs marks a revolutionary advancement in the treatment of NMOSD patients, significantly transforming therapeutic options and positively impacting their prognosis. In this review, we will provide an updated overview of the key immunopathological, clinical, laboratory, and neuroimaging aspects of NMOSD. Additionally, we will critically examine the latest advancements in NMOSD treatment approaches. Lastly, we will discuss key aspects regarding optimization of treatment strategies and their monitoring.

Whole spinal transverse myelitis in neuromyelitis optica spectrum disorder

BACKGROUND

Spinal cord is one of the prominent targets of autoimmune mechanisms in Neuromyelitis Optica Spectrum Disorder (NMOSD). Rarely, NMOSD causes damage to the entire length of the spinal cord, from cervical segments to conus medullaris, which has not been characterized in the existing literature.

MATERIAL AND METHOD

We reviewed medical records, demographic information, and magnetic resonance imaging (MRI) sequences of 174 NMOSD patients from January 2011 to January 2023 who were admitted to Isfahan Multiple Sclerosis center to find patients with whole spinal transverse myelitis (TM).

RESULTS

Whole spinal TM was present in five patients (2.9 %). Three patients were seropositive for Aquaporin-4 (AQP4) antibody; Myelin Oligodendrocyte Glycoprotein antibody (MOG IgG) tested negative for all of them. Lower limb weakness was the most frequent clinical complaint. Two patients presented with optic neuritis; One patient reported having episodes of nausea and vomiting. These patients, overall, yielded a higher expanded disability status scale (EDSS) score than the other NMOSD patients.

CONCLUSION

Whole spinal TM is a rare finding in NMOSD, which is strongly associated with a higher severity and a worse outcome of the disease. The role of anti-AQP4 antibodies in the extent of myelitis in NMOSD has yet to be investigated.

Brain lesion microstructure in neuromyelitis optica spectrum disorder and myelin oligodendrocyte glycoprotein disease

BACKGROUND AND PURPOSE

Neuromyelitis optica spectrum disorder (NMOSD) and myelin oligodendrocyte glycoprotein antibody-associated disease (MOGAD) diagnosis are based on the presence of serological and magnetic resonance imaging (MRI) biomarkers. Diffusion tensor imaging (DTI), neurites orientation dispersion and density imaging (NODDI), and the Spherical Mean Technique (SMT) may be helpful to provide a microstructural characterization of the different types of white matter lesions and give an insight about their different pathological mechanisms. The aim of the study was to characterize microstructural differences between brain typical lesions (TLs) and nontypical lesions (nTLs).

METHODS

A total of 17 NMOSD and MOGAD patients [9 Aquaporin4 (AQP4) + NMO, 2 seronegative-NMO, 6 MOGAD] underwent MRI scans on a 3 Tesla MAGNETON PRISMA. Diffusion parameters (fractional anisotropy; mean diffusivity [MD]; intracellular volume fraction [ICVF]; extra-neurite transverse diffusivity; and extra-neurite MD; neurite signal fraction) were obtained using DTI, NODDI, and SMT. Microstructural parameters within lesions were compared through a generalized linear model using age, sex, and total lesion volume as covariates.

RESULTS

In NMOSD/MOGAD whole cohort (total lesions = 477), TLs showed increased MD and decreased ICVF compared to nTLs (p < .05), indicating higher inflammation and axonal loss. Similar results were found also in the AQP4 + NMO subgroup (decreased ICVF, p < .05). Furthermore, in NMOSD/MOGAD whole cohort and in AQP4 + NMO subgroup, TLs showed a trend toward higher EXRATRANS than nTLs, suggesting a more severe degree of demyelination within TLs.

CONCLUSIONS

TLs and nTLs in NMOSD/MOGAD showed different diffusion MRI-derived microstructural features, with TLs showing a more severe degree of inflammation and fiber disruption with respect to nTLs.

The Role of Glial Fibrillary Acidic Protein as a Biomarker in Multiple Sclerosis and Neuromyelitis Optica Spectrum Disorder: A Systematic Review and Meta-Analysis

There is debate on the role of glial fibrillary acidic protein (GFAP) as a reliable biomarker in multiple sclerosis (MS) and neuromyelitis optica spectrum disorder (NMOSD), and its potential to reflect disease progression. This review aimed to investigate the role of GFAP in MS and NMOSD. A systematic search of electronic databases, including PubMed, Embase, Scopus, and Web of Sciences, was conducted up to 20 December 2023 to identify studies that measured GFAP levels in people with MS (PwMS) and people with NMOSD (PwNMOSD). R software version 4.3.3. with the random-effect model was used to pool the effect size with its 95% confidence interval (CI). Of 4109 studies, 49 studies met our inclusion criteria encompassing 3491 PwMS, 849 PwNMOSD, and 1046 healthy controls (HCs). The analyses indicated that the cerebrospinal fluid level of GFAP (cGFAP) and serum level of GFAP (sGFAP) were significantly higher in PwMS than HCs (SMD = 0.7, 95% CI: 0.54 to 0.86, p < 0.001, I2 = 29%, and SMD = 0.54, 95% CI: 0.1 to 0.99, p = 0.02, I2 = 90%, respectively). The sGFAP was significantly higher in PwNMOSD than in HCs (SMD = 0.9, 95% CI: 0.73 to 1.07, p < 0.001, I2 = 10%). Among PwMS, the Expanded Disability Status Scale (EDSS) exhibited significant correlations with cGFAP (r = 0.43, 95% CI: 0.26 to 0.59, p < 0.001, I2 = 91%) and sGFAP (r = 0.36, 95% CI: 0.23 to 0.49, p < 0.001, I2 = 78%). Regarding that GFAP is increased in MS and NMOSD and has correlations with disease features, it can be a potential biomarker in MS and NMOSD and indicate the disease progression and disability in these disorders.

Early clinical response and complications of therapeutic plasma exchange in central nervous system demyelinating diseases

Background

Appropriate treatment reduces the severity and duration of relapses in demyelinating diseases of Central Nervous System (CNS). If high-dose corticosteroids treatment fails, therapeutic plasma exchange (TPE) is considered as a rescue treatment.

Objectives

This study aimed to investigate early clinical response and complications of TPE and prognostic factors in CNS demyelinating relapses.

Design

This prospective observational study was designed in a tertiary center during one year.

Methods

All adult patients diagnosed corticosteroid-resistant Multiple Sclerosis (MS), NeuroMyelitis Optica Spectrum Disorder (NMOSD), idiotypic Transverse Myelitis or Clinical Isolated Syndrome relapses, were eligible. Clinical response is defined based on Expanded Disability Status Scale (EDSS) at discharge. Clinical and laboratory complications recorded.

Results

Seventy-two patients were analyzed which 58.3% patients were female. MS was diagnosed for 61.1% of cases. Thirty-five patients (48.6%) responded and the mean differences of EDSS significantly decreased 0.60 score (CI95%:0.44-.77). Electrolyte imbalances and thrombocytopenia occurred in 80.6% and 55.6% of cases respectively and 40.3% of patients had systemic reactions. However, 26.4% patients experienced moderate to severe complications. In patients with moderate to severe disability, responders were younger (MD: 8.42 years, CI95%: 1.67-15.17) and had lower EDSS score at admission (median:6, IQR: 5.5-6 against 7.5 IQR: 6.5-8). The risk of failure was higher in active progressive MS patients compared with RRMS patients (OR: 6.06, CI 95%:1.37-26.76). Patients with thrombocytopenia were hospitalized more than others (MD: 1.5 days, CI 95%: 0-3). Females were more prone to hypokalemia and systemic reactions (OR: 3.11, CI 95%:1.17-8.24 and OR: 6.67, CI 95%:2.14-20.81 respectively).

Conclusion

The most common indication of TPE was corticosteroid-resistant severe MS relapses. About half of the patients presented an early clinical response. Lower disability, younger age and RRMS diagnosis are prognostic factors of better response. One out of four patients experienced moderate to severe complications, mainly electrolyte imbalances and systemic reactions. Appropriate interventions against these complications should be considered during TPE, especially in females.

Migraine Risk in Multiple Sclerosis and Neuromyelitis Optica Spectrum Disorder: A Nationwide Cohort Study in South Korea

INTRODUCTION

Although the relationship between migraine and multiple sclerosis (MS) has been reported, the risk of migraine in MS and neuromyelitis optica spectrum disorder (NMOSD) is unclear. Therefore, this study investigated the risk of migraine in the Korean MS and NMOSD populations.

METHODS

This study analyzed claims data from 1,492 patients with MS and 1,551 patients with NMOSD based on diagnostic codes in the Korean National Health Insurance Service. Migraine risk was compared with a control group (matched 1:5 for age, sex, and comorbidities) using Cox proportional hazards analysis. Patients aged <20 years and with previous migraine were excluded.

RESULTS

Migraine risk was higher in patients with MS (adjusted hazard ratio [aHR] 1.37; 95% confidence interval [CI]: 1.15-1.62) but did not differ significantly in patients with NMOSD (aHR 1.05; 95% CI: 0.87-1.27) compared to controls. No significant sex-based differences in migraine risk were observed. Patients with NMOSD showed decreasing risk with age (p for interaction = 0.040). Comorbidities like hypertension, diabetes, or dyslipidemia did not significantly alter migraine risk in either group.

CONCLUSION

The study results revealed an increased risk of migraines in patients with MS but not in patients with NMSOD compared with matched controls.