Myelin Oligodendrocyte Glycoprotein Antibody Persistency in a Steroid-Dependent ADEM Case

Myelin Oligodendrocyte Glycoprotein (MOG) Associated Diseases: Updates in Pediatric Practice

Myelin oligodendrocyte glycoprotein (MOG) is a membrane bound protein found on the surface of oligodendrocyte cells and the outermost surface of myelin sheaths. MOG is posited to play a role as a cell surface receptor or cell adhesion molecule, though there is no definitive answer to its exact function at this time. In the last few decades, there has been a recognition of anti-MOG-antibodies (MOG-Abs) in association with a variety of neurologic conditions, though primarily demyelinating and white matter disorders. In addition, MOG associated disease (MOGAD) appears to have a predilection for pediatric populations and in some patients may have a relapsing course. There has been considerable debate as to whether MOG-Abs are truly directly pathogenic or a disease biomarker associated with neuorinflammatory disease. In this manuscript we will review the current literature surrounding MOGAD, review new clinical phenotypes, discuss treatment and prognosis, and provide insight into potential future directions that studies may focus on.

Adult onset acute disseminated encephalomyelitis: A case report

Acute disseminated encephalomyelitis is an immune mediated demyelinating disorder of the central nervous system, it predominantly affects children in the age group between of 5-8 years. Is most widely thought to be a post-viral, post-vaccination autoimmune phenomenon.

We present a case of 40 years old Pakistani male arrived to ER agitated with decrease level of consciousness and delirium, develop tonic-clonic convulsion and it was relieved by DIAZEPAM. This is the first attack to the patient with no past medical history of similar presentation.

MRI showed supra and infratentorial white matter high T2/FLAIR signal abnormalities, involving supratentorial cortical and subcortical parito-occipital region, also to less extent at deep white matter predominantly right tempro-occipital region in asymmetric pattern. Involvement of juxta cortical and U fibers.

MRI raised the possibility of adult onset Acute disseminated encephalomyelitis, after exclusion of other causes of juxta cortical and U fibers involvement (based on imaging analysis with consideration of clinical presentation and available lab results).

Ophthalmic manifestations of myelin oligodendrocyte glycoprotein-IgG-associated disorder other than optic neuritis: a systematic review

Background/Aims

Optic neuritis (ON) is the primary ophthalmic manifestation of myelin oligodendrocyte glycoprotein-IgG-associated disorder (MOGAD), but numerous reports have expanded the visual manifestations of this condition. The goal of this study was to synthesise the extensive literature on this topic to help ophthalmologists understand when testing for MOG-IgG should be considered.

Method

A systematic review of the English-language literature was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and searches were conducted using Ovid MEDLINE (from January 1, 1948 to April 1, 2020) and Ovid EMBASE (from January 1, 1947 to April 1, 2020). Inclusion criteria included studies describing non-isolated ON ophthalmic manifestations where cell-based assays were used for the detection of MOG antibodies.

Results

Fifty-one articles representing 62 patients with a median age of 32.0 (range 2–65), female gender (51%) and follow-up of 20.0 months (range: 1–240) were included. Twenty-nine patients had non-isolated ON afferent visual manifestations: uveitis, peripheral ulcerative keratitis, acute macular neuroretinopathy, neuroretinitis, venous stasis retinopathy, large preretinal macular haemorrhage, orbital inflammatory syndrome, orbital apex syndrome, optic perineuritis, papilloedema and homonymous visual field defects. Incomplete recovery of ON was associated with a case of Leber’s hereditary optic neuropathy. Efferent ophthalmic manifestations included cranial neuropathies, internuclear ophthalmoplegia, central nystagmus, saccadic intrusions and ocular flutter. Cranial nerve involvement was secondary to enhancement of the cisternal portion or brainstem involvement. All included cases were treated with corticosteroids with 31% of cases requiring additional immunosuppressive therapy.

Conclusions

MOGAD has been associated with various afferent and efferent ophthalmic manifestations apart from isolated ON. Awareness of these findings may result in earlier diagnosis and treatment.

[Clinical features of children with myelin oligodendrocyte glycoprotein antibody-associated disorders]

OBJECTIVE

To study the clinical features and treatment outcome of children with myelin oligodendrocyte glycoprotein (MOG) antibody-associated disorders (MOGAD).

METHODS

A retrospective analysis was performed for the clinical data of 28 children with MOGAD (with 38 demyelinating episodes).

RESULTS

Among the disease spectrums of 28 children with MOGAD, optic neuritis was the most common (12 cases, 43%), followed by acute disseminated encephalomyelitis (9 cases, 32%). Among the 38 demyelinating episodes in the 28 children, there were 29 cases (76%) of lesions in the acute stage on head magnetic resonance imaging (MRI), and most of these lesions were extensive or isolated subcortical white matter lesions. A total of 24 cases of spinal MRI results in the acute stage were recorded, among which there were 11 cases (46%) of spinal lesions. MRI abnormalities of the optic nerve were found in 18 cases of optic neuritis in the acute stage. Of the 28 children, 20 (71%) had an increase in white blood cell count in cerebrospinal fluid, with lymphocytes as the most common type of cells, and 3 children had an increase in protein. The titer of serum MOG antibody was 1:10-1:320 in the 28 children. All 28 children were administered with glucocorticoids, along with immunoglobulin in 18 children. The symptoms of 26 children (93%) were alleviated during follow-up, and only 2 children had neurological sequela of the optic function.

CONCLUSIONS

The clinical manifestations are diverse in children with MOGAD. Immunotherapy is effective and most children have a good prognosis.

Clinical characteristics of myelin oligodendrocyte glycoprotein antibody neuromyelitis optica spectrum disorder

BACKGROUND

Serological antibodies against myelin oligodendrocyte glycoprotein (MOG) are associated with a relapsing autoimmune demyelinating disease of the central nervous system. Initially identified in the context of acute disseminated encephalomyelitis, persistent seropositivity of MOG antibodies is now recognized as a variant of neuromyelitis optica spectrum disorder (NMOSD).

OBJECTIVES

The aim of the study is to describe the epidemiological and clinical features of MOG antibody positive cases and compare our findings with those previously published.

METHODS

This is a retrospective descriptive study of 23 patients with MOG antibody disease who were cared for at Johns Hopkins Hospital over the period from 2015 to 2018. MOG testing was done at Johns Hopkins using the cell based assay (CBA). We describe their epidemiological and clinical features.

RESULTS

Twenty-three patients were included in the study with a female to male ratio of 2.3:1. The mean age of the cohort was 42.6 years, while the mean age at onset was 37 years. The most frequent initial presentation was optic neuritis, followed by ADEM-like encephalopathic clinical picture and transverse myelitis. Five patients showed a monophasic disease course while the rest experienced a relapsing phenotype. Nine patients (39%) experienced immediate relapses on withdrawal of steroids.

CONCLUSIONS

Our cohort showed clinical characteristics comparable with previously published reports of MOG antibody disease worldwide. Unique features of MOG antibody disease are: high frequency of optic neuritis attacks, good long term neurological recovery and sensitivity to steroid use and withdrawal.

Retrospective analysis of children with myelin oligodendrocyte glycoprotein antibody-related disorders

BACKGROUND

Knowledge has been expanding on myelin oligodendrocyte glycoprotein (MOG) antibody-associated central nervous system disorders. We delineate the clinical and paraclinical findings and outcome of our pediatric patients with MOG antibody seropositive disease.

METHODS

We retrospectively analyzed the clinical presentation, cerebrospinal fluid findings, magnetic resonance imaging (MRI) studies, course and outcome of children seropositive for anti-MOG IgG.

RESULTS

Total 20 children with neurological symptoms and serum anti-MOG IgG were identified from six centers in Turkey. Median age at onset was 9 years (mean 8.8 ± 5.0 years, range: 1.5-16.5 years). Final diagnoses were acute disseminated encephalomyelitis (ADEM) (n = 5), ADEM + optic neuritis (n = 4), neuromyelitis optica spectrum disorder (NMOSD) (n = 3), myelitis (n = 2), relapsing optic neuritis (n = 2), multiphasic DEM (n = 3), and unclassified relapsing demyelinating disease (n = 1). Seven/20 (35%) children experienced a single episode while 13/20 (65%) had a least one relapse during follow-up. On MRI, subcortical white matter, brainstem, and corpus callosum were preferentially involved regions. Full recovery was observed in 15/20 (75%) children.

CONCLUSION

MOG autoimmunity in children has a wide clinical spectrum, tendency to relapse, and a favourable outcome compared with other relapsing demyelinating diseases.

Myelin Oligodendrocyte Glycoprotein: Deciphering a Target in Inflammatory Demyelinating Diseases

Myelin oligodendrocyte glycoprotein (MOG), a member of the immunoglobulin (Ig) superfamily, is a myelin protein solely expressed at the outermost surface of myelin sheaths and oligodendrocyte membranes. This makes MOG a potential target of cellular and humoral immune responses in inflammatory demyelinating diseases. Due to its late postnatal developmental expression, MOG is an important marker for oligodendrocyte maturation. Discovered about 30 years ago, it is one of the best-studied autoantigens for experimental autoimmune models for multiple sclerosis (MS). Human studies, however, have yielded controversial results on the role of MOG, especially MOG antibodies (Abs), as a biomarker in MS. But with improved detection methods using different expression systems to detect Abs in patients' samples, this is meanwhile no longer the case. Using cell-based assays with recombinant full-length, conformationally intact MOG, several recent studies have revealed that MOG Abs can be found in a subset of predominantly pediatric patients with acute disseminated encephalomyelitis (ADEM), aquaporin-4 (AQP4) seronegative neuromyelitis optica spectrum disorders (NMOSD), monophasic or recurrent isolated optic neuritis (ON), or transverse myelitis, in atypical MS and in N-methyl-d-aspartate receptor-encephalitis with overlapping demyelinating syndromes. Whereas MOG Abs are only transiently observed in monophasic diseases such as ADEM and their decline is associated with a favorable outcome, they are persistent in multiphasic ADEM, NMOSD, recurrent ON, or myelitis. Due to distinct clinical features within these diseases it is controversially disputed to classify MOG Ab-positive cases as a new disease entity. Neuropathologically, the presence of MOG Abs is characterized by MS-typical demyelination and oligodendrocyte pathology associated with Abs and complement. However, it remains unclear whether MOG Abs are a mere inflammatory bystander effect or truly pathogenetic. This article provides deeper insight into recent developments, the clinical relevance of MOG Abs and their role in the immunpathogenesis of inflammatory demyelinating disorders.