Neuromyelitis optica (NMO) is a well characterised, autoimmune, clinicopathological syndrome, which is uncommon and occurs as an isolated entity. Unlike multiple sclerosis, in NMO, the autoimmunity is humorally mediated and the recent availability of Antiaquaporin antibody testing has increased the positive diagnosis of this condition. NMO can also occur in patients with established Systemic Lupus Erythematosis (SLE) who have multiple autoantibodies. The presence of Antiaquaporin antibody is specific for NMO and is seen in patients with SLE who develop inflammatory CNS disease. However, Neuromyelitis optica occurring as a presenting manifestation of SLE is extremely rare and we report one such case.

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2. Available online at www.sciencedirect.com
journal homepage: www.elsevier.com/locate/apme
Case Report
A case of Neuromyelitis optica as a presenting
manifestation of Systemic Lupus Erythematosis
V.L. Arul Selvan
Consultant Neurologist, Apollo Institute of Neurosciences, Chennai 600078, India
a r t i c l e i n f o
Article history:
Received 25 July 2013
Accepted 7 August 2013
Available online 4 September 2013
Keywords:
Neuromyelitis optica
Antiaquaporin antibody
Hypothyroidism
Catheter
a b s t r a c t
Neuromyelitis optica (NMO) is a well characterised, autoimmune, clinicopathological
syndrome, which is uncommon and occurs as an isolated entity. Unlike multiple sclerosis,
in NMO, the autoimmunity is humorally mediated and the recent availability of Anti-aquaporin
antibody testing has increased the positive diagnosis of this condition. NMO can
also occur in patients with established Systemic Lupus Erythematosis (SLE) who have
multiple autoantibodies. The presence of Antiaquaporin antibody is specific for NMO and is
seen in patients with SLE who develop inflammatory CNS disease. However, Neuromyelitis
optica occurring as a presenting manifestation of SLE is extremely rare and we report one
such case.
Copyright ª 2013, Indraprastha Medical Corporation Ltd. All rights reserved.
1. Case report
A 51-year-old female came to the hospital with history of
constricting pain over the thorax bilaterally of 3 days duration
withweakness of both lower limbs and acute urinary retention
of one day duration. There was no history of fever or trauma.
Her past history consisted of 15 years of hypothyroidism, hy-pertension
of 6 years duration, Diabetes of 10 years and pe-ripheral
vascular disease of 5 years duration with past history
of DVT of left leg for which she was on Acitrome, clopidogrel,
Levothyroxine, oral hypoglycemics and amlodipine. There was
no previous neurological illness. No history of prolonged fever,
joint pains, skin lesions or renal impairment. On neurological
examination, she was Alert and oriented and her speech and
cranial nerve examination were normal. She had Quad-riparesis
with a power of 4/5 in the upper limb and a power of
1/5 at hip, 2/5 at knee and 3/5 distally. Abdominal reflex was
absent and plantars were extensor. The Biceps and Triceps
jerks were brisk, Supinator and Knee jerks were sluggish and
Ankle jerk was absent. Vibration sense was reduced in the
lower limbs and touch was impaired below T5. Pain sensation
was reduced below T9. There was no spinal tenderness or
deformity. She was catheterised in view of the urinary reten-tion.
A clinical diagnosis of Acute myeloradiculopathy at the
cervicodorsal level was made and patient was further inves-tigated.
MRI revealed longitudinally extensive myelitic
changes from C5 to the conus with faint enhancement with
contrast (Fig. 1). CSF study revealed a Protein of 110mg/dl with
glucose of 92 mg/dl and 100 RBCs and 110 WBCs with 92%
lymphocytes. Routine Blood investigations were normal and
ESR was 2 mm/h and Sr Creatinine was 0.5 mg/dl. VEP was
normal. A diagnosis of Acute Disseminated Encephalomyelitis
was made and the patient started on 5 sittings of Plasma ex-change
of 2.5 L each. The patient was managed by a multi-specialitymedical
teamfor her systemic problems. The patient
started improving by the 4th cycle and was discharged on the
E-mail address: drarulselvan@yahoo.com.
a p o l l o m e d i c i n e 1 0 ( 2 0 1 3 ) 2 2 6 e2 2 9
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http://dx.doi.org/10.1016/j.apme.2013.08.005

3. a pol l o m e d i c i n e 1 0 ( 2 0 1 3 ) 2 2 6 e2 2 9 227
Fig. 1 e a: STIR image showing longitudinally extensive myelitis. b: Axial T2 image at dorsal level showing hyperintensity
in the centre of the dorsal cord.
11th day when she was able to walk with support with Urinary
catheter in situ. After 4 weeks she had almost completely
recovered and the catheter was removed.
10 months from the initial event, she came back with
transient blurring of vision of right eye associated with
numbness of the right upper limb with slipping of objects
from the hand. MRI Brain revealed a flame shaped lesion in
the left frontoparietal white matter with faint enhancement
with the possibility of demyelination infarct (Fig. 2). VEP done
showed prolongation of P100 latency on the right side and CSF
study was normal. She was treated with 3 days of Solumedrol.
She improved completely in one month.
21 months after the initial event she got readmitted with
history of loss of appetite and loss of weight of 3 months
duration with intermittent low grade fever followed by 2 day
history of weakness of all four limbs (4/5) with bladder
retention and right inferior quadrantanopia. MRI revealed
longitudinally extensive lesion from C5 to lower dorsal with
Fig. 2 e a: Diffusion Weighted Image showing the acute infarct in the left parietal region. b: FLAIR coronal imaging showing
the flame shaped lesion (the 2nd episode occurred 10 months after the 1st neurological event).

4. 228 a p o l l o me d i c i n e 1 0 ( 2 0 1 3 ) 2 2 6 e2 2 9
patchy lesion in the left occipital lobe (Fig. 3). Her ESR was
100 mm/h and CRP was normal. She was started on a course of
IV Solumedrol 1 g/day for 5 days with Plasma exchange of 5
cycles. She again made a remarkable recovery.
At this point, Antiaquaporin-4 antibody was tested positive
and she was diagnosed as Neuromyelitis optica. She had
sudden drop in Hemoglobin and Coombs test became positive.
Her ANA and dsDNA were also strongly positive. C3 and C4
levels were reduced. Her clinical picture fulfilled the criteria
for Systemic Lupus Erythematosis. Antiphospholipid anti-bodies
were negative. A diagnosis of Neuromyelitis optica in
the setting of SLE was made and she was started on oral ste-roids
along with Mycophenolate, which was later changed to
Azathioprine due to leucopenia.
2. Discussion
The most widely accepted diagnostic criteria for NMO is: optic
neuritis and acute myelitis with atleast 2 of the following 3: 1.
Spinal cord MRI lesion extending over 3 or more vertebral
segments. 2. Brain MRI not meeting diagnostic criteria for MS
and 3. Positive Antiaquaporin-4 antibody in serum.1 In 2004, a
specific pathogenic antibody called NMO-IgG was discovered.
This antibody is targeted against the aquaporin-4 (AQP4)
water channel widely expressed in the optic nerves, the spinal
cord and the periventricular regions. This discovery clearly
placed NMO in the B-cell disease category, which from a
pathophysiological perspective mimics vasculitis rather than
MS.2 Binding of NMO-IgG to AQP4 expressed at the astrocyte
membrane can initiate complement activation and
complement-dependent cytotoxicity. Antiaquaporin-4 anti-body
also damages oligodendrocytes through an excitotoxic
mechanism resulting from glutamate homeostasis disruption
in astrocytes.3
With wider availability of Antiaquaporin antibody, the
clinical spectrum of NMO has widened and includes patients
with isolated severe optic neuritis with poor recovery and dor-sal
brainstemlesions with persistent hiccups and nausea.4,5
Neuropsychiatric manifestations occur in 50% of patients
with SLE sometime in the course of their illness but presen-tation
with neurological illness is seen in less than 3% of pa-tients.
In SLE, headache (54%) and seizures (42%) are the
commonest CNS manifestations.6 The other important man-ifestations
are psychosis, dementia, stroke, myelopathy, pe-ripheral
neuropathy and cranial nerve involvement.7 There
are several case reports of the association of NMO with SLE.
The proposed explanation is a shared environmental/genetic
Fig. 3 e a: Sagittal T2W image showing the hyperintensity mainly in the dorsal cord (the 3rd episode happened 21 months
after the first). b: Left occipital patchy hyperintensity in axial FLAIR image.

5. a pol l o m e d i c i n e 1 0 ( 2 0 1 3 ) 2 2 6 e2 2 9 229
predisposition to autoimmunity.8 Neuromyelitis optica
mostly occurs in the setting of established SLE. However,NMO
presenting as the first manifestation of SLE is extremely rare
and there is an isolated case report of a patient who developed
clinical SLE 7 years after the onset of NMO.9
NMO antibodies are uncommon in SLE and in one study
among 326 patients with SLE including 6 patients with
neurological involvement, only 1 patient tested positive and
he had myelitis.10 In another series of patients with connec-tive
tissue disorders with neurological involvement consistent
with NMO, aquaporin-4 antibody was positive in 78% of in-dividuals
whereas it was negative in all the patients without
CNS involvement. Hence Antiaquaporin antibody is not a
nonspecific autoantibody seen in SLE and its presence signi-fied
CNS disease consistent with NMO.11,12 On the contrary,
ANA positivity is common in NMO and often is nonspecific. In
one study, ANA was positive in 43.8% of patients with NMO
spectrum disease, whereas only 2% of patients fulfilled criteria
for SLE.12
NMO is distinctly different from multiple sclerosis in clin-ical
manifestation, etiopathogenesis and response to treat-ment
and the use of the NMO antibody may help to
differentiate the two in difficult situations. Compared to MS,
patients with NMO may be left with severe permanent deficits
even after a single clinical event, hence differentiating the two
early has important practical implications. Unlike in MS, the
interferon activity is increased in SLE and NMO and this may
explain the worsening that is often seen when interferon is
used in SLE or NMO.13 Plasma exchange is effective in NMO
but has no role in MS. Relapse prevention is by immunomo-dulation
in MS and by immunosuppression in NMO.
In NMO, the initial treatment of choice is Pulse IV meth-ylprednisolone
and patients who do not show a quick
response are treated with Plasma exchange. The response to
treatment in NMO is highly variable, but there are several
reports of individual patients with NMO and SLE who have
responded remarkably to either glucocorticoids or Plasma
exchange over prolonged periods of upto 35 years.14 In one
report Cyclophosphamide was used successfully in 2 patients
who had a overlap of NMO and SLE.15 In patients with re-fractory
NMO, Rituximab is recently being recommended.4
The interesting features in the present patient are 1. Pres-ence
of multiple comorbidities. 2. Having two attacks of NMO
prior to the development of clinical SLE. 3. Dramatic response
to Plasma exchange during both the attacks of extensive
myelitis. 4. Two attacks involving the brain.
3. Conclusion
NMO is a CNS demyelinating disease with a characteristic
presentation and now, has a distinct biomarker. It may be
associated with other autoimmune diseases, especially
SLE and Sjogren’s syndrome. A high index of suspicion is
necessary to diagnose one, when the other disease is present.
An early and aggressive immunosuppressive treatment is
imperative in patients with NMO to prevent devastating
sequelae.
Conflicts of interest
The author has none to declare.
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