Clinical and Prognostic Analysis of Autoantibody-Associated CNS Demyelinating Disorders in Children in Southwest China

Clinical characteristics and factors associated with recurrence and long-term prognosis in patients with MOGAD

Objective

To describe the clinical features, treatment, and prognostic factors affecting recurrence and long-term adverse outcomes of myelin oligodendrocyte antibody-associated disease (MOGAD).

Methods

In this retrospective cohort study, the records of patients diagnosed with MOGAD at Zhengzhou University First Affiliated Hospital between January 2018 and March 2023 were analyzed, and factors associated with recurrence and poor long-term prognosis were identified using logistic regression.

Results

Of the 91 patients, 69 (76%) were new cases, 39 (43%) were female, and 47 (52%) were children (<18 years). Clinical manifestations included optic neuritis (ON) in 13 (14%), transverse myelitis (TM) in 14 (15%), brain disease in 37 (41%), and mixed encephalomyelitis in 27 (30%). The prevalence of acute disseminated encephalomyelitis (ADEM) was significantly higher in children than in adults (43% versus 18%, p = 0.012), whereas the prevalence of TM was significantly higher in adults (30% versus 2%, p < 0.001). Combined steroid and intravenous immunoglobulin (IVIG) treatment during hospitalization was more frequent in children than in adults (36% versus 11%, p = 0.006), and children had a better short-term prognosis than that in adults at discharge (median [interquartile range (IQR)]) Expanded Disability Status Scale [EDSS]: 1 [0-1] versus 2 [0-4.75], p = 0.007; Modified Rankin Score [mRS]: 1 [0-1] versus 1 [0-2], p = 0.006). Visual impairment was a risk factor for recurrence (odds ratio [OR]: 4.22, 95% confidence interval [CI]: 1.24-14.38, p = 0.022). A higher EDSS score at discharge (OR: 5.05, 95% CI: 1.27-20.07, p = 0.021)and more previous episodes (OR: 9.24, 95% CI: 1.35-63.10, p = 0.023), were associated with a poor long-term prognosis; whereas steroid therapy for >5 weeks at first diagnosis (OR: 0.001, 95% CI: 0.00-0.33, p = 0.019) and type I isoelectric focusing pattern (OR: 0.004, 95% CI: 0.00-0.402, p = 0.043) were associated with favorable long-term prognosis.

Conclusion

After the first episode, steroid maintenance for an appropriate period following discharge is important for achieving a favorable long-term prognosis, particularly in patients with a high EDSS score at discharge and those at a heightened risk of recurrence.

Pediatric MOG antibody-positive encephalitis with normal brain magnetic resonance imaging: a new spectrum associated with MOG antibodies?

Objective

To facilitate the accurate identification of clinical characteristics associated with myelin oligodendrocyte glycoprotein (MOG) antibody positive encephalitis in children presenting with normal brain magnetic resonance imaging (MRI) findings.

Method

Patients hospitalized at Children's Hospital of Chongqing Medical University from January 2016 to May 2024, who were positive for MOG antibodies and exhibited encephalitis symptoms with normal brain MRI findings, were retrospectively analyzed.

Results

A total of 17 patients (7 males and 10 females; mean age: 9.2 ± 2.8 years) were enrolled in the study. The most prevalent clinical symptoms were fever (17/17), with a median duration of 15 days (IQR: 7.5-21 days), headaches (17/17), mild alterations in mental status (17/17), seizures (6/17), vomiting (6/17), decreased binocular vision (2/17), and hemiplegia (1/17). The majority of cases (15/17) exhibited leukocytosis in peripheral blood (mean: 20.63 ± 7.09 × 109/L) accompanied by an elevated neutrophil ratio. C-reactive protein (CRP) and procalcitonin (PCT) levels were normal in 13 patients (13/17). Cerebrospinal fluid (CSF) leukocyte counts were elevated in all patients (median: 82/mm3; IQR: 49-155/mm3). Six patients (6/17) had elevated CSF protein levels (mean: 1.01 ± 0.38 g/L). CSF glucose levels were normal across all patients. Next-generation sequencing of CSF was performed in 10 patients, all yielding negative results. All patients had a serum MOG antibodies titer of ≥1:32, and six children (6/17) had a CSF MOG antibody titer of ≥1:32. All patients showed clinical improvement after immunotherapy. Only one patient (1/17) experienced a relapse.

Conclusion

For patients presenting with encephalitis and normal brain MRI findings, early testing for anti-MOG antibody should be considered if they exhibit the following characteristics: (1) persistent fever; (2) elevated peripheral blood white blood cell (WBC) counts, with normal or slightly elevated PCT and CRP levels; (3) mild elevation of CSF WBC counts, normal or mildly elevated protein levels, and normal CSF glucose levels; and (4) ineffectiveness of antibiotic or antiviral therapy. Encephalitis with normal brain MRI may be regarded as a potential new spectrum associated with MOG antibodies, meriting additional exploration and consideration.

Oral corticosteroid dosage and taper duration at onset in myelin oligodendrocyte glycoprotein antibody-associated disease influences time to first relapse

BACKGROUND

We sought to identify an optimal oral corticosteroid regimen at the onset of myelin oligodendrocyte glycoprotein antibody-associated disease (MOGAD), which would delay time to first relapse while minimising cumulative corticosteroid exposure.

METHODS

In a retrospective multicentre cohort study, Cox proportional hazards models examined the relationship between corticosteroid course as a time-varying covariate and time to first relapse. Simon-Makuch and Kaplan-Meier plots identified an optimal dosing strategy.

RESULTS

We evaluated 109 patients (62 female, 57%; 41 paediatric, 38%; median age at onset 26 years, (IQR 8-38); median follow-up 6.2 years (IQR 2.6-9.6)). 76/109 (70%) experienced a relapse (median time to first relapse 13.7 months; 95% CI 8.2 to 37.9). In a multivariable model, higher doses of oral prednisone delayed time to first relapse with an effect estimate of 3.7% (95% CI 0.8% to 6.6%; p=0.014) reduced hazard of relapse for every 1 mg/day dose increment. There was evidence of reduced hazard of relapse for patients dosed ≥12.5 mg/day (HR 0.21, 95% CI 0.07 to 0.6; p=0.0036), corresponding to a 79% reduction in relapse risk. There was evidence of reduced hazard of relapse for those dosed ≥12.5 mg/day for at least 3 months (HR 0.12, 95% CI 0.03 to 0.44; p=0.0012), corresponding to an 88% reduction in relapse risk compared with those never treated in this range. No patient with this recommended dosing at onset experienced a Common Terminology Criteria for Adverse Events grade >3 adverse effect.

CONCLUSIONS

The optimal dose of 12.5 mg of prednisone daily in adults (0.16 mg/kg/day for children) for a minimum of 3 months at the onset of MOGAD delays time to first relapse.

Less common phenotypes of myelin oligodendrocyte glycoprotein antibody-related diseases in children deserve more attention

BACKGROUND

To facilitate the identification of less common clinical phenotypes of myelin oligodendrocyte glycoprotein antibody-associated disease (MOGAD) in children.

METHODS

We retrospectively reviewed medical records of 236 patients with MOGAD. The following phenotypes were considered to be typical for MOGAD: ADEM, ON, TM, and NMOSD. Less common onset clinical phenotypes were screened out; their clinical and magnetic resonance imaging (MRI), diagnosis, treatment, and prognosis were summarized and analyzed.

RESULTS

16 cases (6.8%) presented as cortical encephalitis, with convulsions, headache, and fever as the main symptoms. 15 cases were misdiagnosed in the early period. 13 cases (5.5%) showed the overlapping syndrome of MOGAD and anti-N-methyl-D aspartate receptor encephalitis (MNOS), with seizures (92.3%) being the most common clinical symptom. 11 cases (84.6%) showed relapses. The cerebral leukodystrophy-like phenotype was present in seven cases (3.0%), with a recurrence rate of 50%. Isolated seizures without any findings on MRI phenotype was present in three cases (1.3%), with the only clinical symptom being seizures of focal origin. Three cases (1.3%) of aseptic meningitis phenotype presented with prolonged fever.

CONCLUSION

40/236 (16.9%) of children with MOGAD had less common phenotypes. Less common clinical phenotypes of pediatric MOGAD are susceptible to misdiagnosis and deserve more attention.

IMPACT

This is the first comprehensive analysis and summary of all less commonl clinical phenotypes of MOGAD in children, while previous studies have only focused on a specific phenotype or case reports. We analyzed the characteristics of MOGAD in children and further revealed the reasons why these less common clinical phenotypes are prone to misdiagnosis and deserve more attention. Our research on treatment has shown that early detection of MOG antibodies and early treatment are of great significance for improving the prognosis of these patients.

Pediatric myelin oligodendrocyte glycoprotein antibody-associated disease in southern China: analysis of 93 cases

Objective

To study the clinical features of children diagnosed with myelin oligodendrocyte glycoprotein antibody-associated disease (MOGAD) in southern China.

Methods

Clinical data of children diagnosed with MOGAD from April 2014 to September 2021 were analyzed.

Results

A total of 93 children (M/F=45/48; median onset age=6.0 y) with MOGAD were involved. Seizures or limb paralysis was the most common onset or course symptom, respectively. The most common lesion locations in brain MRI, orbital MRI, and spinal cord MRI were basal ganglia and subcortical white matter, the orbital segment of the optic nerve, and the cervical segment, respectively. ADEM (58.10%) was the most common clinical phenotype. The relapse rate was 24.7%. Compared with the patients without relapse, relapsed patients had a longer interval from onset to diagnosis (median: 19 days VS 20 days) and higher MOG antibody titer at onset (median: 1:32 VS 1:100) with longer positively persistent (median: 3 months VS 24 months). All patients received IVMP plus IVIG at the acute phase, and 96.8% of patients achieved remission after one to three courses of treatment. MMF, monthly IVIG, and maintaining a low dose of oral prednisone were used alone or in combination as maintenance immunotherapy for relapsed patients and effectively reduced relapse. It transpired 41.9% of patients had neurological sequelae, with movement disorder being the most common. Compared with patients without sequelae, patients with sequelae had higher MOG antibody titer at onset (median: 1:32 VS 1:100) with longer persistence (median: 3 months VS 6 months) and higher disease relapse rate (14.8% VS 38.5%).

Conclusions

Results showed the following about pediatric MOGAD in southern China: the median onset age was 6.0 years, with no obvious sex distribution difference; seizure or limb paralysis, respectively, are the most common onset or course symptom; the lesions of basal ganglia, subcortical white matter, the orbital segment of the optic nerve, and cervical segment were commonly involved in the CNS MRI; ADEM was the most common clinical phenotype; most had a good response to immunotherapy; although the relapse rate was relatively high, MMF, monthly IVIG and a low dose of oral prednisone might effectively reduce relapse; neurological sequelae were common, and possibly associated with MOG antibody status and disease relapse.

Attack phenotypes and disease course in pediatric MOGAD

Myelin oligodendrocyte glycoprotein antibody-associated disease (MOGAD) is an autoimmune demyelinating condition that affects children differently than adults. We performed a literature review to assess the presentation and clinical course of pediatric MOGAD. The most common initial phenotype is acute disseminated encephalomyelitis, especially among children younger than five years, followed by optic neuritis (ON) and/or transverse myelitis. Approximately one-quarter of children with MOGAD have at least one relapse that typically occurs within three years of disease onset and often includes ON, even if ON was not present at onset. Clinical risk factors for a relapsing course have not been elucidated.

Clinical features of the first attack with leukodystrophy‐like phenotype in children with myelin oligodendrocyte glycoprotein antibody‐associated disorders

BACKGROUND

Myelin oligodendrocyte glycoprotein antibody-associated disorders (MOGAD) is identified autoimmune disorder with a predominance in paediatric patients, and the disease spectrum has expanded with clinical and radiological patterns. The aim of the study was to describe the clinical characteristics of the first attack with leukodystrophy-like phenotype with MOGAD in children.

METHODS

Patients hospitalized at the Children's Hospital of Chongqing Medical University from June 2017 to October 2021 with positive MOG antibodies and phenotype of leukodystrophy-like (symmetric white matter lesions) were retrospectively analyzed. Cell-based assays (CBAs) were used to test MOG antibodies.

RESULTS

Four cases from 143 MOGAD patients were recruited, with two females and two males. The age of onset is all under 6 years old. At the last follow-up, four cases exhibited a monophasic course, including ADEM in three patients and encephalitis in one patient. The mean EDSS score at onset was 4.62 ± 2.93, and the modified Rankin score (mRS) was 3.00 ± 1.82. First-attack symptoms include fever, headache, vomiting, seizure, loss of consciousness, emotional and behavioural disorder, and ataxia. The brain MRI showed prominent extensive and essentially symmetric distribution lesions in the white matter. All patients showed clinical and partial radiological improvement after intravenous immunoglobulin and/or glucocorticoid treatment.

CONCLUSION

The first attack with MOGAD onset of leukodystrophy-like phenotype was more frequently seen in younger children than other phenotype patients. The patients may show impressive neurologic disorders, but most patients who receive immunotherapy have a good prognosis.

Effectiveness and tolerability of different therapies in preventive treatment of MOG-IgG-associated disorder: A network meta-analysis

Background

Immunotherapy has been shown to reduce relapses in patients with myelin oligodendrocyte glycoprotein antibody-associated disorder (MOG-AD); however, the superiority of specific treatments remains unclear.

Aim

To identify the efficacy and tolerability of different treatments for MOG-AD.

Methods

Systematic search in Pubmed, Embase, Web of Science, and Cochrane Library databases from inception to March 1, 2021, were performed. Published articles including patients with MOG-AD and reporting the efficacy or tolerability of two or more types of treatment in preventing relapses were included. Reported outcomes including incidence of relapse, annualized relapse rate (ARR), and side effects were extracted. Network meta-analysis with a random-effect model within a Bayesian framework was conducted. Between group comparisons were estimated using Odds ratio (OR) or mean difference (MD) with 95% credible intervals (CrI).

Results

Twelve studies that compared the efficacy of 10 different treatments in preventing MOG-AD relapse, including 735 patients, were analyzed. In terms of incidence of relapse, intravenous immunoglobulins (IVIG), oral corticosteroids (OC), mycophenolate mofetil (MMF), azathioprine (AZA), and rituximab (RTX) were all significantly more effective than no treatment (ORs ranged from 0.075 to 0.34). On the contrary, disease-modifying therapy (DMT) (OR=1.3, 95% CrI: 0.31 to 5.0) and tacrolimus (TAC) (OR=5.9, 95% CrI: 0.19 to 310) would increase the incidence of relapse. Compared with DMT, IVIG significantly reduced the ARR (MD=-0.85, 95% CrI: -1.7 to -0.098). AZA, MMF, OC and RTX showed a trend to decrease ARR, but those results did not reach significant differences. The combined results for relapse rate and adverse events, as well as ARR and adverse events showed that IVIG and OC were the most effective and tolerable therapies.

Conclusions

Whilst DMT should be avoided, IVIG and OC may be suited as first-line therapies for patients with MOG-AD. RTX, MMF, and AZA present suitable alternatives.

Risk Factors and Nomogram for Predicting Relapse Risk in Pediatric Neuromyelitis Optica Spectrum Disorders

Background

Neuromyelitis optica spectrum disorders (NMOSDs) are attack-relapsing autoimmune inflammatory diseases of the central nervous system, which are characterized by the presence of serological aquaporin-4 (AQP4) antibody. However, this disorder is uncommon in children, and AQP4 antibody was often found to be seronegative. However, some pediatric patients diagnosed with NMOSDs were tested to be positive for myelin oligodendrocyte glycoprotein (MOG) antibody. The previous investigations of pediatric NMOSDs were usually focused on the clinical presentation, treatment responses, and long-term prognoses, but little is known about the risk factors predicting NMOSD relapse attacks in a shorter time, especially, for Chinese children.

Methods

We retrospectively identified 64 Chinese pediatric patients, including 39 positive for AQP4 antibody, 12 positive for MOG antibody, and the rest negative for AQP4 and MOG antibodies. Independent risk factors predicting relapse in 1-year follow-up were extracted by multivariate regression analysis to establish a risk score model, its performance evaluation was analyzed using receiver operating characteristic (ROC) curve, and the independent risk factors related to relapse manifestation were also explored through multivariate logistic analysis. A nomogram was generated to assess relapse attacks in 1-year follow-up. Thirty-five patients from 3 other centers formed an external cohort to validate this nomogram.

Results

Four independent relapsed factors included discharge Expanded Disability Status Scale (EDSS) (p = 0.017), mixed-lesion onset (p = 0.010), counts (≧1) of concomitant autoantibodies (p = 0.015), and maintenance therapy (tapering steroid with mycophenolate mofetil (MMF), p = 0.009; tapering steroid with acetazolamide (AZA), p = 0.045; and tapering steroid only, p = 0.025). The risk score modeled with these four factors was correlated with the likelihood of relapse in the primary cohort (AUC of 0.912) and the validation cohort (AUC of 0.846). Also, our nomogram exhibited accurate relapse estimate in the primary cohort, the validation cohort, and the whole cohort, but also in the cohorts with positive/negative AQP4 antibody, and noticeably, it performed predictive risk improvement better than other factors in the concordance index (C-index), net reclassification improvement (NRI), and integrated discrimination improvement (IDI).

Conclusions

The risk score and nomogram could facilitate accurate prognosis of relapse risk in 1-year follow-up for pediatric NMOSDs and help clinicians provide personalized treatment to decrease the chance of relapse.