Mrs. X is a 33-year-old woman who presented with recurrent episodes of visual symptoms, asymmetric motor weakness in her lower and upper limbs, and imbalance while walking over the past 4 months. Imaging showed lesions in her spinal cord and optic nerves. She responded well to steroid treatment in the past but not this time. Laboratory tests were negative for anti-aquaporin-4 antibodies but positive for anti-MOG antibodies. This case presents a diagnostic dilemma between NMO and MS, as anti-MOG antibodies can be present in some NMO spectrum disorder cases without anti-AQP4 antibodies. Rituximab treatment was initiated.

1. An Interesting Case for
Discussion
Is It MS or NMO
Dr.ARUL SELVAN Unit
Presenter: Dr.M.Ramesh Babu

2. History
• Mrs.X 33 yrs young woman, house wife, educated , Rt.
Handed person, from Chennai, presented with chief
complaints of
• Imbalance while walking
• weakness of both lower limbs and left UL
• Blurring of vision left Eye
• Profuse sweating and fatiguability - since 3 weeks.

3. HOPI
• She started complaining of weakness in both LL and Lt.UL
Imbalance while walking - 3weeks, feels stiff in both the
LL, difficulty in getting up, gripping the sandals, difficulty in
while walking and sways to Rt.side. Difficulty in raising the
LT. shoulder and gripping the objects.
• No h/o LBA, trauma, fall, fever, no sensory symptoms and
bowel bladder symptoms.
• Blurring of vision - Lt.Eye - blurred images, no diplopia,
redness, watering, pain on eye movements, drooping of
eye lid.

4. • No h/o weakness in Rt. UL, dysarthria, dysphagia, HOH,
tinnitus
• Profuse sweating all over the body - intermittently while
walking
• Fatiguability - duration of 3 weeks
• No h/o headache, nausea, vomiting, neck pain, back pain,
loss of weight or appetite

5. Past History
• She had complaints in OCT 2017, Blurring of Lt.Eye,
weakness of Rt.LL and imbalance while walking -
approached to a Local Neurologist - received 5 doses of
pulse steroid - recovered completely from the weakness
and imbalance with 80 % improvement in left eye vision
• Later she started taking Ayurvedic medicine
• Again in last week of DEC 2017, presented with above
mentioned complaints.
• No other significant medical history

6. • No significant family history
• Personal History - Vegeterain , Appitite - N, No wt. loss
• No drug/ toxin exposure

7. On Examination
• Pt. Well built , moderately nourished , BMI - 22.95kg/m2
• NO P I C C L E
• Vitals : stable, no postural drop
• CNS Examination
• HMF - N
• speech - N
• Cranial nerve:
• CN II - Mild blurring of Lt. eye + , Fundus - N
• other CN examination - N

8. • Motor system : Tone - Inc,
• power - shoulder - 5/5 4-/5
• elbow 5/5 4-/5
• wrist (F/E) 5/5 4-/5
• Hip 4-/5 4-/5
• knee 4-/5 4-/5
• planti Flex 4/5 4/5
• Dorsi flex 3/5 4/5

9. • DTR’S - UL - 2+
• LL- Exaggerated - No clonus
• Plantar - B/L Extensor
• No sensory deficit
• Cerebellar signs : F-N-T Lt. Impaired
• Gait - Ataxic / Spastic - sways more to Rt.
• Cranium & spine - N
• Other systems - N

10. Summary
• Mrs.X 33 yrs young woman with recurrent symptoms of
visual , asymmetric motor symptoms of both lower limbs
and upper limbs with a duration of 4 months , with out any
sensory or incontinence symptoms , good response to
steroids
• Possibilities: Demyelinating disorder
• NMO / MS

11. Investigations
• HB- 11.6 gm%
• PCV - 36%
• WBC - 8.24 cells/cumm
• Platelets - 2.12 lakhs
• Blood glucose - 98 mg/dl
• B.Urea - 13 mg/dl
• S.Creatinine - 0.5mg/dl
• S.sodium - 140 meq/l
• S. k+ - 3.8 meq/l
• LFT - N

12. • Anti Aquaporin antibodies- neg
• Anti MOG antibodies - awiated
• Oligoclonal bands - not done
• CSF fluid analysis - N

13. Imaging

24. • No improvement after 3 doses of pulse steroids
• Started on Inj. Rituxumab 1000mg iv - got discharged
• On follow up

27. Factors to influence sensitivity in AQP4-Abassay:
- specificity varies between 90 and100%*
- sensitivity of 60-90%* (FACSassay88%**)
- Seropositive conversion at relapse in somecases
- Seronegative conversion by immunosuppression
- Sero-negative but CSF-positivein rareinstances
*Update on the diagnosis and treatment of neuromyelitis optica: Recommendations of the NEMOS,
C.Trebst,Neurol. 2014; 261(1):1–16.
**Updated estimate of AQP4-IgG serostatus and disability outcome in neuromyelitis optica, Y.Jiao,
Neurology. October 1, 2013 vol. 81 no. 141197-1204
Cell-Based-Assay
Mouse Tissue-
BasedAssayELISA

28. MOG-Ab presentinsomeanti-AQP4-Ab-seronegativeNMOSD
Distinction between MOGantibody-positive and AQP4antibody-positive NMO spectrum disorders. Satoet al.
Neurology2014;82:474–481
Neuromyelitis Optica Spectrum Disorders With AQP-4and MOGAntibodies: AComparative Study. Kitley et al. JAMA
Neurol. 2014;71(3):276-283
No NMOSDpatients were
double-positive
No female predominance
Fewerattacks & betterrecovery