Epidemiology of Pediatric NMOSD in Germany and Austria

Pediatric intensive care unit admissions network-rationale, framework and method of operation of a nationwide collaborative pediatric intensive care research network in Germany

The Pediatric Intensive Care Unit Admissions (PIA) network aims to establish a nationwide database in Germany to gather epidemiological, clinical, and outcome data on pediatric critical illness. The heterogeneity of pediatric patients in intensive care units (PICU) poses challenges in obtaining sufficient case numbers for reliable research. Multicentered approaches, such as patient registries, have proven effective in collecting large-scale data. However, Germany lacks a systematic registration system for pediatric intensive care admissions, hindering epidemiological and outcome assessments. The PIA network intends to address these gaps and provide a framework for clinical and epidemiological research in pediatric intensive care. The network will interconnect PICUs across Germany and collect structured data on diagnoses, treatment, clinical course, and short-term outcomes. It aims to identify areas for improvement in care, enable disease surveillance, and potentially serve as a quality control tool. The PIA network builds upon the existing infrastructure of the German Pediatric Surveillance Unit ESPED and utilizes digitalized data collection techniques. Participating units will complete surveys on their organizational structure and equipment. The study population includes patients aged ≥28 days admitted to participating PICUs, with a more detailed survey for cases meeting specific criteria. Data will be collected by local PIA investigators, anonymized, and entered into a central database. The data protection protocol complies with regulations and ensures patient privacy. Quarterly data checks and customized quality reports will be conducted to monitor data completeness and plausibility. The network will evaluate its performance, data collection feasibility, and data quality. Eligible investigators can submit proposals for data analyses, which will be reviewed and analyzed by trained statisticians or epidemiologists. The PIA network aims to improve pediatric intensive care medicine in Germany by providing a comprehensive understanding of critical illness, benchmarking treatment quality, and enabling disease surveillance.

Role of serostatus in pediatric neuromyelitis optica spectrum disorders: A nationwide multicentric study

BACKGROUND

Neuromyelitis optica spectrum disorders (NMOSD) are immune-mediated inflammatory disorders of the central nervous system (CNS) mostly presenting as optic neuritis and acute myelitis. NMOSD can be associated with seropositivity for aquaporin 4 antibody (AQP4 IgG), myelin oligodendrocyte glycoprotein antibody (MOG IgG), or can be seronegative for both. In this study, we retrospectively examined our seropositive and seronegative pediatric NMOSD patients.

METHOD

Data were collected from all participating centres nationwide. Patients diagnosed with NMOSD were divided into three subgroups according to serology: AQP4 IgG NMOSD, MOG IgG NMOSD, and double seronegative (DN) NMOSD. Patients with at least six months of follow-up were compared statistically.

RESULTS

The study included 45 patients, 29 female and 16 male (ratio:1.8), mean age 15.16 ± 4.93 (range 5.5-27) years. Age at onset, clinical manifestations, and cerebrospinal fluid findings were similar between AQP4 IgG NMOSD (n = 17), MOG IgG NMOSD (n = 10), and DN NMOSD (n = 18) groups. A polyphasic course was more frequent in the AQP4 IgG and MOG IgG NMOSD groups than DN NMOSD (p = 0.007). The annualized relapse rate and rate of disability were similar between groups. Most common types of disability were related to optic pathway and spinal cord involvement. Rituximab in AQP4 IgG NMOSD, intravenous immunoglobulin in MOG IgG NMOSD, and azathioprine in DN NMOSD were usually preferred for maintenance treatment.

CONCLUSION

In our series with a considerable number of double seronegatives, the three major serological groups of NMOSD were indistinguishable based on clinical and laboratory findings at initial presentation. Their outcome is similar in terms of disability, but seropositive patients should be more closely followed-up for relapses.

Neuromyelitis optica spectrum disorders: a review with a focus on children and adolescents

Neuromyelitis optica spectrum disorder (NMOSD) is a rare and severe inflammatory disorder of the central nervous system (CNS). It is strongly associated with anti-aquaporin 4 antibodies (AQP4-IgG), and it mainly affects young women from non-white ethnicities. However, ∼ 5 to 10% of all cases have onset during childhood. Children and adolescents share the same clinical, radiologic, and laboratory presentation as adults. Thus, the same NMOSD diagnostic criteria are also applied to pediatric-onset patients, but data on NMOSD in this population is still scarce. In seronegative pediatric patients, there is a high frequency of the antibody against myelin oligodendrocyte glycoprotein (MOG-IgG) indicating another disease group, but the clinical distinction between these two diseases may be challenging. Three drugs (eculizumab, satralizumab, and inebilizumab) have been recently approved for the treatment of adult patients with AQP4-IgG-positive NMOSD. Only satralizumab has recruited adolescents in one of the two pivotal clinical trials. Additional clinical trials in pediatric NMOSD are urgently required to evaluate the safety and efficacy of these drugs in this population.

Sex and gender differences in autoimmune demyelinating CNS disorders: Multiple sclerosis (MS), neuromyelitis optica spectrum disorder (NMOSD) and myelin-oligodendrocyte-glycoprotein antibody associated disorder (MOGAD)

Multiple sclerosis (MS), Neuromyelitis optica spectrum disorder (NMOSD) and Myelin-Oligodendrocyte-Glycoprotein antibody associated disorder (MOGAD) are demyelinating disorders of the central nervous system (CNS) of autoimmune origin. Here, we summarize general considerations on sex-specific differences in the immunopathogenesis and hormonal influences as well as key clinical and epidemiological elements. Gender-specific issues are widely neglected starting with the lacking separation of sex as a biological variable and gender comprising the sociocultural components. As for other autoimmune diseases, female preponderance is common in MS and NMOSD. However, sex distribution in MOGAD seems equal. As in MS, immunotherapy in NMOSD and MOGAD is crucial to prevent further disease activity. Therefore, we assessed data on sex differences of the currently licensed disease-modifying treatments for efficacy and safety. This topic seems widely neglected with only fragmented information resulting from post-hoc analyses of clinical trials or real-world post-marketing studies afflicted with lacking power and/or inherent sources of bias. In summary, biological hypotheses of sex differences including genetic factors, the constitution of the immune system and hormonal influences are based upon human and preclinical data, especially for the paradigmatic disease of MS whereas specific data for NMOSD and MOGAD are widely lacking. Epidemiological and clinical differences between men and women are well described for MS and to some extent for NMOSD, yet, with remaining contradictory findings. MOGAD needs further detailed investigation. Sex-specific analyses of safety and efficacy of long-term immunotherapies need to be addressed in future studies designed and powered to answer the pressing questions and to optimize and individualize treatment.

Longitudinally Extensive Transverse Myelitis: One Disease, Variable Outcomes—A Case Series

Longitudinal extensive transverse myelitis (LETM) is a rare form of widespread inflammation of the spinal cord causing T2 hyperintensity in spinal magnetic resonance imaging (MRI) extending across three or more vertebral segments. It is an acute onset of sensory, motor, and autonomic dysfunction of variable etiology with a likely poor outcome. We present a case series of three cases wherein children between the ages of 4 and 13 years had diverse symptoms from gradual painless loss of vision in both eyes with headache, vomiting and seizure, and a normal central nervous system examination except involvement of the optic nerve to another child with abdominal pain, urinary retention and constipation for 3 days with exaggerated DTR, and patchy sensory loss without any definite sensory level, and to the third child with fever and weakness of lower limbs, hypotonia and grade 1–2/5 power in lower limbs and normal upper limb power. Contrast-enhanced MRI spine of all children showed long segment T2 hyperintensity with variable involvement of the brain. The first two children were treated with pulsed dose methylprednisolone, and the last child received intravenous immunoglobulin followed by methylprednisolone. All were followed with oral prednisolone. LETM has a varied presentation with different etiologies. Antineuromyelitis optica immunoglobulin G (IgG) antibody (Aquaporin-4 IgG) and antimyelin oligodendrocyte glycoprotein antibody are strongly recommended though they may not be locally available or not affordable. Early and aggressive immunomodulatory therapy may help faster recovery, as did with two of our three children.

[Epidemiology of neuromyelitis optica spectrum disorder]

Neuromyelitis optica spectrum disorder (NMOSD) is a group of rare and mostly severe autoimmune demyelinating central nervous system disorders which prevalence is 0.7-1 per 100.000 population and incidence is 0.037-0.73 per 100.000 person-years. NMOSD may present as a combination of uni- or bilateral optic neuritis, transverse myelitis or lesions of brain stem and other brain regions. The symptoms are mostly relapsing (up to 97.5%) and progressive. Occurrence of relapses is associated with seropositivity for aquaporin-4 (up to 80% of NMOSD patients) and bears a less favorable prognosis (mortality up to 32%). Women seropositive for aquaporin 4 constitute 90% of NMOSD patients. Compared to other demyelinating disorders, NMOSD is characterized by late onset (mean age is about 39 years) and association with other autoimmune disorders, including systemic lupus erythematosus, myasthenia gravis and Sjogren's syndrome. A genetic predisposition was found among Blacks and Asians, with HLA-DRB1*03:01 gene associated with higher risk of NMOSD in Asians. The course of the disease tends to be more severe in Blacks. There are clusters of an increased incidence of NMOSD in the Carribeans and in the Far East. Continued increase of prevalence and incidence of NMOSD worldwide compels continued epidemiological research in order to provide early diagnosis and treatment for this disorder.

Immunization in multiple sclerosis and other childhood immune-mediated disorders of the central nervous system: A review of the literature

Childhood is a period where most vaccines are administered in order to build-up immunological memory, and immunization against vaccine-preventable diseases is an essential part of child care and health. The administration of vaccines to children with inflammatory diseases is a frequent point of concern for parents and physicians. Published information on the relation between vaccines and autoinflammatory diseases of the central nervous system (CNS) consists of case and cohort studies and reviews, in great majority on adult patients. Vaccines do not have any established causative or triggering effects on these diseases. Another issue is the immunization schedule of patients with autoinflammatory CNS diseases, specifically the interactions between the disorder, the clinical status, the treatment and the vaccine. In this review, we summarize the existing information between autoinflammatory disorders of the CNS and vaccines in childhood and underline the points to be considered under various treatment regimens.