This presentation consist information about unspoken and less well known variants of GBS as well as CIDP. Also it includes information about diagnosis and management.
Anti-MOG Antibody-Associated Diseases - Prof. Ayman NassefTalal Thabet
In this slides deck, Prof. Ayman Nassef clarifies the role of Myelin Olidodendrocyte Glycoprotein (MOG) in demyelinating conditions, and explains how MOG-IgGs cause damage of myelin and axons and the impact of such damage on the disease.
This presentation consist information about unspoken and less well known variants of GBS as well as CIDP. Also it includes information about diagnosis and management.
Anti-MOG Antibody-Associated Diseases - Prof. Ayman NassefTalal Thabet
In this slides deck, Prof. Ayman Nassef clarifies the role of Myelin Olidodendrocyte Glycoprotein (MOG) in demyelinating conditions, and explains how MOG-IgGs cause damage of myelin and axons and the impact of such damage on the disease.
Neuromyelitis optica spectrum disorders (NMOSD) is an autoimmune disorder of young adults' results from astrocytic aquaporin–4 (AQP–4) channelopathy. The AQP–4 IgG antibodies may be present in the context of some paraneoplastic disorders which should be suspected when NMOSD occurs in elderly patients.
references:
1-European Academy of Neurology/Peripheral Nerve Society guideline on diagnosis and treatment of chronic inflammatory demyelinating polyradiculoneuropathy: Report of a joint Task Force—Second revision.
2-Chronic Inflammatory Demyelinating Polyradiculoneuropathy and Its Variants By Kelly Gwathmey, MD
3-Patient Journey in CIDP: Burden, Symptoms, and Diagnosis Jeffrey A. Allen, MD; Richard A. Lewis, MD
Neuromyelitis optica spectrum disorders (NMOSD) is an autoimmune disorder of young adults' results from astrocytic aquaporin–4 (AQP–4) channelopathy. The AQP–4 IgG antibodies may be present in the context of some paraneoplastic disorders which should be suspected when NMOSD occurs in elderly patients.
references:
1-European Academy of Neurology/Peripheral Nerve Society guideline on diagnosis and treatment of chronic inflammatory demyelinating polyradiculoneuropathy: Report of a joint Task Force—Second revision.
2-Chronic Inflammatory Demyelinating Polyradiculoneuropathy and Its Variants By Kelly Gwathmey, MD
3-Patient Journey in CIDP: Burden, Symptoms, and Diagnosis Jeffrey A. Allen, MD; Richard A. Lewis, MD
Imaging of spinal cord acute myelopathiesNavni Garg
This presentation provides a comprehensive review of imaging of causes of acute myelopathies and a systemic approach for narrowing down the differentials
references:
Phases and Phenotypes of Multiple Sclerosis By Orhun H. Kantarci, MD.
Diagnosis of Multiple Sclerosis By Jiwon Oh, MD, PhD, FRCPC
Nature Reviews | Disease Primers
Multiple sclerosis Massimo Filippi1,2*, Amit Bar- Or3, Fredrik Piehl4,5,6, Paolo Preziosa1,2, Alessandra Solari7, Sandra Vukusic8 and Maria A. Rocca1,2
CONCEPT OF NODOPATHIES AND PARANODOPATHIES.pptxNeurologyKota
emergence of autoimmune neuropathies and role of nodal and paranodal regions in their pathophysiology.
Peripheral neuropathies are traditionally categorized into demyelinating or axonal.
dysfunction at nodal/paranodal region key for better understanding of patients with immune mediated neuropathies.
antibodies targeting node and paranode of myelinated nerves have been increasingly detected in patients with immune mediated neuropathies.
have clinical phenotype similar common inflammatory neuropathies like Guillain Barre syndrome and chronic inflammatory demyelinating polyradiculoneuropathy
they respond poorly to conventional first line immunotherapies like IVIG
This presentation briefs out the approach of dementia assessment in line with consideration of recent advances. Now the pattern of assessment has evolved towards examining each individual domain rather than lobar assessment.
This presentation contains information about Dementia in Young onset. Also it describes the etiologies, clinical feature of common YOD & their management.
Entrapment Syndromes of Lower Limb.pptxNeurologyKota
This presentation contains information about the various Entrapment syndromes of Lower limb in descending order of topography. It also contains information about etiology, clinical features and management of each of these entrapment syndromes with special emphasis on electrodiagnostic confirmation.
This presentation consist information about Brain death with special emphasis to differences between Indian and Western Guidelines. Also consist information about Organ transplantation and related act.
Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
- WOMEN’S HEALTH: FERTILITY PRESERVATION
- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
- ARTIFICIAL INTELLIGENCE AND ETHICS
- GENE THERAPY
- BEYOND BORDERS: GLOBAL INITIATIVES FOR DEMOCRATIZING LIFE SCIENCE TECHNOLOGIES AND PROMOTING ACCESS TO HEALTHCARE
- ETHICAL CHALLENGES IN LIFE SCIENCES
- Prix Galien International Awards Ceremony
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
Couples presenting to the infertility clinic- Do they really have infertility...Sujoy Dasgupta
Dr Sujoy Dasgupta presented the study on "Couples presenting to the infertility clinic- Do they really have infertility? – The unexplored stories of non-consummation" in the 13th Congress of the Asia Pacific Initiative on Reproduction (ASPIRE 2024) at Manila on 24 May, 2024.
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
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2. Introduction
• Inflammatory disorders of the central nervous system characterized by
severe, immune-mediated demyelination and axonal damage
predominantly targeting optic nerves and spinal cord.
• The first clinical descriptions of NMO emerged over a century ago by
Devic and Gault
• Over time, significant variation in the presenting features, clinical course,
and the degree of accumulated disability in patients with presumed NMO
has been observed.
3. Introduction
• It was previously believed that NMO and multiple sclerosis represented
one disease entity, with variable phenotypes and expression.
• The discovery of a disease-specific serum NMO-IgG antibody has led to
increased understanding of a diverse spectrum of disorders.
• NMO is now recognized as a distinct clinical entity based on unique
immunologic features.
4. Introduction
• In 2007, the term NMO spectrum disorders (NMOSD) was introduced.
1. AQP4-IgG-seropositive patients with limited or inaugural forms of
NMO
2. Encompassed the cerebral, diencephalic, and brainstem lesions that
occur in a minority of patients
3. AQP4-IgG-seropositive patients with coexisting autoimmune disorders
4. Patients diagnosed with opticospinal MS
5. Epidemiology
• Prevalence of NMO in various studies ranges from 0.5 to 10 per 100,000
• India it was 2.7/100,000
• Female: male – 9:1 (recurrent NMO)
• In monophasic NMO:- men and women are affected equally
• Median age of onset is 32 to 41 years,
6. Epidemiology
• NMO is usually sporadic, though a few familial cases have been reported.
• Other population studies of HLA in NMO indicate that the DRB1*0301
and DRB1*1037 alleles are associated with increased risk.
7. Pathogenesis
• An autoimmune inflammatory cascade leads to florid demyelination and
axonal injury.
• Necrosis and cavitation typically involve both gray and white matter.
• NMO is thought to be primarily mediated by the humoral immune system.
The spectrum of neuromyelitis optica, lancet neurology 2oo7; 6;805
8. (A)Extensive demyelination of the
grey matter and white matter at the
level of the thoracic cord (Luxol
fast blue-periodic acid Schiff)
(B) Extensive axonal injury, necrosis
and associated cavitation
(Bielschowsky silver impregnation)
(C) and (D) The inflammatory
infiltrate contains perivascular and
parenchymal eosinophils and
granulocytes
The spectrum of neuromyelitis optica, lancet neurology 2oo7; 6;805
9. Histopathologic examination of NMO
lesions shows immunoglobulin and
complement deposits
The spectrum of neuromyelitis optica, lancet neurology 2oo7; 6;805
10. Pathogenesis
• Several lines of evidence support an autoimmune pathogenesis for NMO:-
1. NMO disease-specific autoantibody, the NMO-IgG antibody, also
referred to as the aquaporin-4 (AQP4) autoantibody
2. NMO is frequently associated with systemic autoimmune disorders.
3. Antinuclear autoantibodies are common in patients with NMO patients
who lack evidence of a systemic disorder
4. Therapeutic plasma exchange and immunosuppressive therapies are
beneficial for treatment and prevention of acute NMO attacks
The spectrum of neuromyelitis optica, lancet neurology 2oo7; 6;805
11. AQP4is expressed at the blood–brain barrier, on
the ‘‘foot-like’’ processes of astrocytes, whereas
MOG is expressed by oligodendrocytes and on the
outermost surface of myelin sheaths
AQP4-IgG is synthesised in the bloodstream by
mature B-cells. On crossing the blood–brain barrier
it activates complement-mediated astrocyte damage
MOG-IgG is also produced outside of the
CNS. It causes a demyelination
The spectrum of neuromyelitis optica, lancet neurology 2oo7; 6;805
12. Clinical features
• Hallmark features of NMO include acute attacks of optic neuritis or
transverse myelitis with a typically relapsing course
• Attacks most often occur over days, with variable degrees of recovery
over weeks to months.
• Central nervous system involvement outside of the optic nerves and spinal
cord is recognized in patients with NMO and NMOSD.
• No clinical features are disease-specific, some are highly characteristic
13. Clinical features
Optic neuritis:-
• Optic neuritis presents with varying degrees of vision loss
• Associated with eye pain that worsens with movement of the eye.
• Visual loss is generally more severe in NMO
• Majority of optic neuritis attacks in NMO are unilateral, sequential optic
neuritis in rapid succession or bilateral simultaneous optic neuritis is
highly suggestive of NMO
EFNS guidelines on diagnosis and management of neuromyelitis optica. Eur J Neurol 2010;
17:1019.
14. Clinical features
Transverse myelitis:-
• It is defined as spinal cord dysfunction developing over hours or days in
the absence of a structural spinal cord lesion
• Symmetric paraparesis or quadriparesis, bladder dysfunction, and sensory
loss below the level of the spinal cord lesion
• Accompanying symptoms may include paroxysmal tonic spams of the
trunk or extremities, radicular pain, or Lhermitte sign
• Typically have a longer extent of spinal cord demyelination often
involving three or more vertebral segments , a condition termed
longitudinally extensive transverse myelitis (LETM)
15. Brain Involvement
• 50 to 60% of NMOSD patient has brain involvement.
• 40% brain lesions are symptomatic
• 15-20% brain lesions are present during first clinical attack.
• Common sites involved are:-
1. Medulla(34%)
2. Supratentorial (29%) and infratentorial white matter (23%)
3. Midbrain (21%)
4. Cerebellum (18%)
5. Thalamus (13%) and hypothalamus (5%).
16. Brain Involvement
• Common manifestations:-
1. Encephalopathy,
2. Seizures
3. Hemiparesis
4. Aphasia
5. Vomiting, or hiccups
• Extensive hemispheric lesions over white matter, basal ganglia, and
corpus callosum manifesting as limbic encephalitis, parkinsonism, and
coma respectively.
17. Brain Involvement
• Large confluent lesions in frontal, parietal, and occipital lobes were
observed manifesting clinically as homonymous hemianopia, aphasia, and
cognitive impairment.
• Posterior reversible encephalopathy:-
• Patients with NMO predisposed to a higher frequency of posterior
reversible encephalopathy syndrome
• When subjected to blood pressure fluctuations or therapies causing rapid
fluid shifts,
• Manifests as reversible encephalopathy, seizures, headache, and vision
symptoms.
18. Brain Involvement
Fulminant cerebral demyelination :-
• Large hemispheric confluent cavitary lesions, presumably due to a large
area of inflammation with necrosis, are also observed in NMO.
• The lesions were vasogenic edema associated with inflammation
• In rare cases, fulminant diffuse vasogenic edema can lead to brain
herniation and death
19. Brain Involvement
Endocrinopathies:-
• NMO may initially be seen with endocrinopathies
• Hypothalamic dysfunction :-amenorrhea, galactorrhea, hyperphagia and
weight gain
• Diabetes insipidus
• Hypothyroidism,
• Due to lesions seen in the hypophysis and hypothalamus
20. Brainstem symptoms
• Involvement of the brainstem occurs in almost one-third of patients NMO
and NMOSD
• Brainstem is rich in AQP4 ag.
• Number and pattern of brainstem involvement has no difference in
pediatric and adult age group.
• Common in AQP4 Ig G Ab positive patients.
21. Brainstem symptoms
• Mc brainstem symptoms :- vomiting and hiccups.
• Due to area postrema involvement.
• Small percentage of NMOSD patients with this symptoms have lesion in
area postrema on conventional imaging.
• Lesion in this area do not progress to demyelination or necrosis.
22. Brainstem symptoms
• Brainstem lesion predominantly involve medulla and pons that sometimes
caused multiple cranial neuropathy.
• These symptoms are reversible in most cases but sequelae may be
observed especially in hearing loss and oculomotor dysfunction.
• Acute and subacute bulbar dysfunction with ataxia in the form of BE can
occur.
• May lead to acute neurogenic respiratory failure and death.
23. Muscle involvement
• Creatine kinase leakage as a result of AQP4-IgG-induced, complement-
mediated sarcolemmal injury may be a potential mechanism for hyperCKemia.
• The sCK levels of patients in the acute phase of NMOSD were significantly
higher.
• NMOSD-associated myopathy seems to be characterized by mild muscle
symptoms with prominent hyperCKemia and minimal changes on conventional
pathological staining
Int J Neurosci. 2016 Oct;126(10):863-6. doi: 10.3109/00207454.2015.1113175.
Epub 2015 Nov 19.
24. Cutaneous manifestation
• Nonspecific cutaneous manifestations such as erythematous
rash, sclerodactyly, and bilateral edema of the hands have been
noted in the setting of NMOSD, although these have been
limited to isolated case reports
26. Paediatric NMOSD
• Most clinical, neuroimaging, and laboratory characteristics of pediatric
NMOSD are similar to those of adult-onset disease except:-
1. The female preponderance may be of lower magnitude
2. A greater proportion of children may have monophasic disease
3. Detection of a LETM MRI lesion associated with acute myelitis may be less specific
for NMOSD
• Children with an ADEM-like event that includes optic neuritis and LETM,
may be required observation of the clinical course and testing of AQP4-
IgG status to achieve confident diagnosis.
International consensus diagnostic criteria for neuromyelitis optica spectrum disorders
Neurology® 2015;85:177–189
28. NMOSD coexisting with subacute combined
degeneration
• AQP4 is also expressed in diverse organs such as the stomach, skeletal
muscle, inner ear, and kidneys.
• AQP4-IgG may inhibit the production of intrinsic factor and gastric acid
secretion by parietal cells with resultant vitamin B12 malabsorption.
• Ishii et al reported the case of a 36-year-old Japanese woman who
simultaneously had NMOSD with AQP4-IgG and subacute combined
degeneration
Neuropsychiatric Disease and Treatment 2017:13 2653–2660
29. NMOSD coexisting with anti-NMDAR
encephalitis
• NMOSD overlapping anti-NMDAR encephalitis is increasingly noted, as
evidenced by the simultaneous detection of both NMDAR antibodies and
AQP4-IgG in serum samples
• In 2017, Ran et al succinctly summarized the clinical characteristics of 34
patients who presented with both NMOSD and anti-NMDAR encephalitis
• Further studies are still needed to thoroughly investigate the association
between NMOSD and anti-NMDAR encephalitis
Neuropsychiatric Disease and Treatment 2017:13 2653–2660
30. Multisystem involvement in neuromyelitis optica
• 13-year-old girl initially presented with
nausea and intractable vomiting
• creatine kinase (CK) to 5,018, lactate
dehydrogenace (LDH) to 1000,
• 4 months later with blindness due to
left-sided optic neuritis
• Antibodies to aquaporin-4 (AQP-4) were
positive in the serum
• treated with methylprednisolone pulse
followed by rituximab
Langille MM, Desai J. Multisystem involvement in neuromyelitis optica. Ann Indian
Acad Neurol 2015;18, Suppl S1:56-8
31. Disease pattern
• The presenting symptom was usually either ON or TM, especially among
seropositive patients.
• Simultaneous TM and ON, bilateral ON, and monophasic course were
relatively more common presentations among seronegative patients
• Has a relapsing course in > 90%
• Relapse occurs within first year in 60 percent of patients and within three
years in 90 percent
32. Disease pattern
• Young-onset disease commonly presenting with ON and had a high risk of
visual disability.
• An older age of onset was significantly associated with motor disability.
• Seropositive and seronegative patients did not differ in terms of age of
onset, time to relapse, relapse rates and mortality rate.
33. Disease pattern
• Periaqueductal ,grey matter, hypothalamic, and area postrema lesions may
be more often seen in seropositive patients.
• Patients with cerebral presentations may have continued brain attacks
without involvement of optic nerves or spinal cord
34. Diagnostic criteria
• Original criteria proposed by Wingerchuk et al., in 1996 was revised in
2006 after the discovery of anti AQP4-IgG.
Absolute Criteria
• Transverse myelitis and optic neuritis
Supportive Criteria
• At least two of the following features:
1. MRI brain negative/nondiagnostic for MS
2. MRI spinal cord lesion extending over ≥3 vertebral segments (LETM)
3. NMO-IgG seropositivity
38. Red flags: Findings atypical for NMOSD
International consensus diagnostic criteria for neuromyelitis optica spectrum disorders
Neurology® 2015;85:177–189
39. Red flags: Findings atypical for NMOSD
International consensus diagnostic criteria for neuromyelitis optica spectrum disorders
Neurology® 2015;85:177–189
40. Red flags: Findings atypical for NMOSD
International consensus diagnostic criteria for neuromyelitis optica spectrum disorders
Neurology® 2015;85:177–189
41. Investigations
Cerebrospinal fluid (CSF) analysis:-
• CSF pleocytosis can include or be dominated by neutrophils.
• CSF cell count is greater than 50 cells/ll in 13–35% of patients and in a
few cases up to 1000 cells/ll .
• CSF pleocytosis :- LETM > ON
• Increased protein levels are present in 46–75% of cases
• Transient presence of OCB in NMO. (30%)
42. Investigations
Cerebrospinal fluid (CSF) analysis:-
• Neurofilament heavy chain (NfH) and glial fibrillary acidic protein
(GFAP) levels are significantly higher in the CSF of NMO than in patients
with MS .
• Analysis of CSF provides supportive data for the diagnosis of NMO and
CSF should be obtained during or shortly after an acute attack.
• The findings are useful, but not highly sensitive or specific
43. Investigations
• Electrophysiological study:-
• VEP, SEP and BAEP examination in patients with NMO
frequently reveal abnormalities.
• peripheral nerve conduction studies are expected to be normal.
44. Investigations
Aquaporin 4 antibody:-
• Aquaporin-4 (AQP4) is a water channel protein highly concentrated in:-
1. spinal cord gray matter
2. periaqueductal and periventricular regions
3. astrocytic foot processes at the blood-brain barrier.
• Serum testing is generally more sensitive than CSF testing.
Jacob A, et al. J Neurol Neurosurg Psychiatry 2013;84:922–930. doi:10.1136/jnnp-2012-302310
45. Investigations
Aquaporin 4 antibody:-
• Most commonly used method:-Indirect immunofluorescence (IIF)
(sensitivity of 58–76% and a specificity of 85–99%)
• In addition, there are four other assay techniques:-
1. Cell-based assays (CBA), ( 80% sensitivity)
2. Radioimmunoprecipitation assays,
3. Fluoroimmunoprecipitation assays (FIPA) (53%)
4. Enzyme-linked immunosorbent assays (ELISA) (60%)
Jacob A, et al. J Neurol Neurosurg Psychiatry 2013;84:922–930. doi:10.1136/jnnp-2012-302310
46. Investigations
Aquaporin 4 antibody:-
• Prognostic marker for high-risk syndromes
• NMO-IgG/AQP4 antibodies can be present in patients years before and
after clinical disease activity.
• It also remains to be determined whether NMO-IgG/AQP4 antibodies are
a reliable marker of disease activity and treatment response.
Jacob A, et al. J Neurol Neurosurg Psychiatry 2013;84:922–930. doi:10.1136/jnnp-2012-302310
47. Investigations
Anti-myelin associated oligoglycoprotein (anti- MOG):-
• A proportion of patients with AQP4-IgG seronegative NMOSD have been
found to have serum antibodies against myelin-oligodendrocyte
glycoprotein (MOG-IgG).
• In MOG-IgG disease the sex difference is less (M:F, 1:3) and only 9% of
patients have a second autoimmune disorder
• Complete recovery from attacks appears more common with MOG-IgG
J Neurol DOI 10.1007/s00415-017-8445-8
48. Investigations
Other laboratory tests:-
• CBC, ESR, vitamin B12
• Antibodies associated with connective disorders (ANA/ENA, anti-ds-
DNA antibodies, lupus anticoagulant, antiphospholipid antibodies, ANCA,
etc.
• Treponema pallidum hemagglutination assay,
• Paraneoplastic antibodies (in particular, anti-CV2/CRMP5 and anti-Hu).
56. Treatment:- acute exacerbation
Steroids:-
• Initial or recurrent episodes are usually treated with high-dose intravenous
methylprednisolone (1 g daily for three to five consecutive days).
• Acute NMO symptoms respond to short courses of high-dose intravenous
corticosteroids in up to 80% of patients within 1–5 days
• Treatment is generally well tolerated
• Median ARR reduced from 1.48 to 0.49
57. Treatment:- acute exacerbation
Plasma exchange:-
• Therapeutic plasmapheresis was effective in patients with severe
symptoms that fail to improve or progress despite treatment with
corticosteroids.
• Plasma exchange should be done up to seven treatments every other day.
(1–1.5 ltr plasma volume per exchange)
58. Treatment:- acute exacerbation
IV Immunoglobulin:-
• Might be effective in NMO given the potential humoral
immunopathogenesis.
• However, there are only very few supportive data in the literature.
• A case series of eight Spanish NMO patients showed positive results using
bimonthly IVIg treatment (0.7 g/kg body weight/day for 3 days) for up to
2 years
59. Treatment:- acute exacerbation
• In case of unresponsiveness to steroids, early initiation of a rescue therapy
with plasmapheresis is indicated.
• Prior to escalation therapy, a repeated course of high-dose corticosteroids
may be considered
60. Prevention of relapse
• Principle of management - quickly achieve and maintain remission with
corticosteroids, choose an immunosuppressant, establish it, and then start
a gradual withdrawal of corticosteroids aiming to minimise its side effects.
• Since the biological effects of many corticosteroid-sparing agents take
months to have an effect, corticosteroids may be needed in many patients
at doses 0.5–1 mg/kg for up to 3 months after an attack, and then slowly
tapered off over further 6–12 months.
61. Prevention of relapse
Azathioprine:-
• Purine synthesis inhibitor and interferes with the proliferation of cells,
especially leucocytes.
• Azathioprine (75–100 mg daily) in combination with oral prednisolone (1
mg/kg/ daily).
• Haematological evaluations are required every 2–4 weeks, the dosage may
be reduced in the course and treatment duration of up to 5 years may be
considered
62. Prevention of relapse
• Side effects:-
• gastrointestinal complaints and leucopenia very common (>10%)
• infections, allergy and haematological disturbances were common (1–10%)
Mycophenolate mofetil:-
• Mycophenolate (p.o. 1–3 g/ day)
• The occurrence of treatment effect is more rapid for mycophenolate than for
azathioprine
63. Prevention of relapse
Cyclophosphamide:-
• Non-specific immunosuppressant that affects both T-cell and B-cell
functions
• I.v. cyclophosphamide range from 7 to 25 mg/kg every month over a
period of 6 months.
• Uromitexan administration with every dose needs to be included for
prevention of haemorrhagic cystitis.
• Occurrence of amenorrhea and sepsis has to be taken into account
64. Prevention of relapse
Methotraxate:-
• Inhibition of dihydrofolate reductase and has anti-inflammatory and
immunomodulatory effect
• Mainly prescribed as second-line drug, was associated with a significant
decrease in the median annualized relapse rate (ARR) and was relatively
well-tolerated.
65. Prevention of relapse
Mitoxantrone;-
• An anthracenedione antineoplastic agent that intercalates with DNA and
inhibits both DNA and RNA synthesis
• 12 mg/m2 monthly for 6 months, followed by three more treatments, each
3 months apart.
• Bone marrow suppression, opportunistic infection and cardiomyopathy.
• Amenorrhoea is a major concern in the treatment of young women
• Therapy related acute leukaemia
66. Prevention of relapse
Rituximab:-
• A chimeric anti-CD20 monoclonal antibody capable of depleting mature
and precursor B cells
• Dose:-(1)375 mg/m2 infused once per week for 4 weeks
(2) 1000 mg infused twice, with a 2-week interval between the infusions
• To date, no incidents of progressive PML have been reported in NMO.
• Whether long-term RX treatment at lower doses suppress disease activity
is requires further investigation to confirm.
67. Prevention of relapse
Medication ARR
Prednisolone 1.48 to 0.49
Azathioprine 2.1 to 0.6
Mycophenolate 1.3 to 0.09
Rituximab 2.5 to 0
Mitoxantrone 2.4 to 0.4
68. Drugs that are ineffective or worsen NMO
• Interferon beta
• Natalizumab
• Fingolimod
• Glatiramer acetate is also not beneficial in NMOSD
69. Prevention of relapse
• Long-term treatment options should be initiated as soon as the diagnosis of
NMO is made
• Prevention of attacks is the key issue for reducing permanent disability.
• Seronegative NMO is treated in the same way as seropositive NMO
• Immunosuppressants seem to work to varying degrees, and cost, convention,
convenience, availability, side effects and familiarity of the treating physician to
the drug are the guiding factors in its choice at present.
EFNS GUIDELINES/CME ARTICLE ,European Journal of Neurology 2010, 17: 1019–1032
doi:10.1111/j.1468-1331.2010.03066
72. Emerging therapy
• Combination therapies
• Stem cell trials are still in their infancy; three are in progress, two with
haematopoietic cells and one using mesenchymal umbilical cord cells
• Humanised anti-CD20 monoclonal antibodies, ofatumumab and
ocrelizumab
• specific protective monoclonal antibodies that bind AQP4
(Aquaporumab)
EFNS GUIDELINES/CME ARTICLE ,European Journal of Neurology 2010, 17: 1019–1032
doi:10.1111/j.1468-1331.2010.03066
73. Emerging therapy
Serping 1
• serine protease inhibitor that controls bradykinin generation and prevents
the initiation of classical and lectine pathway activation
• A proof-of-concept trial has used purified human C1-esterase inhibitor
Cinryze as an adjunct to IVMP in the treatment of ten patients with acute
exacerbation.
74. Emerging therapy
Complement inhibitors:-
• Eculizumab is a C5-specific humanized monoclonal antibody that inhibits C5a
generation
• 14 AQP4-IgG seropositive patients with highly active disease were treated with
eculizumab for 12 months .12 patients became relapse-free and two had possible
relapses.
• Dose of 500mg IV each week for 4 weeks, 900mg IV the fifth week, and thereafter
900mg every 2 weeks for 48 weeks
EFNS GUIDELINES/CME ARTICLE ,European Journal of Neurology 2010, 17: 1019–1032
doi:10.1111/j.1468-1331.2010.03066
76. Symptomatic treatment
Neuropathic pain:-
• Antiepileptic drugs (gabapentin, pregabalin, carbamazepine), or
• low-dose tricyclic antidepressants (amitriptyline and nortriptyline).
• Painful tonic spasms usually respond to carbamazepine or topiramate
Fampridine:- blocks potassium channels
• Improves ambulation has been safely used in a few patients with
NMOSD and may be similarly beneficial to MS.
Antispamodic medication:- baclofen or tizanidine
J Neurol DOI 10.1007/s00415-017-8445-8
77. Symptomatic treatment
Bladder dysfunction:-
• Antimuscarinic agents (oxybutynin, tolterodine and solifenacin) and
mirabegron
• Improving urinary frequency and urgency
• Intermittent self-catheterisation
• Injection of botulinum toxin into the bladder wall
• Nocturia, cautious use of desmopressin nasal spray at bedtime will reduce
the volume of urine produced overnight.
J Neurol DOI 10.1007/s00415-017-8445-8
78. Key points…..
• A single clinical manifestation is not diagnostic when AQP4-IgG is not
detected.
• No single characteristic is exclusionary but some are considered red flags
that signal the possibility of alternative diagnoses
• NMOSD must be considered in the differential diagnosis in patients
presenting with short myelitis lesions.
International consensus diagnostic criteria for neuromyelitis optica spectrum disorders
Neurology® 2015;85:177–189
79. Key points…..
• AQP4-IgG seronegative patients with clinical and neuroimaging features
of NMOSD should be screened for anti-MOG antibody.
• Current immunotherapeutic strategies are the same for relapsing NMO
and NMOSD, regardless of AQP4-IgG serologic status
80. Future directions….
• Expanding understanding of pathogenesis and clinical scenario
• Role of established biomarker and invention of new biomarker
• Diagnostic criteria for pediatric and monophasic NMOSD
• Development of new immunosuppressive therapy
81. References
• Bradely textbook of neurology, 7th edition
• Uptodate.com
• The spectrum of neuromyelitis optica, lancet neurology 2oo7; 6;805
• International consensus diagnostic criteria for neuromyelitis optica
spectrum disorders ,Neurology® 2015;85:177–189
• J Neurol DOI 10.1007/s00415-017-8445-8
82. References
• EFNS GUIDELINES/CME ARTICLE ,European Journal of
Neurology 2010, 17: 1019–1032
• Jacob A, et al. J Neurol Neurosurg Psychiatry 2013;84:922–930.
• Neuropsychiatric Disease and Treatment 2017:13 2653–2660
• Langille MM, Desai J. Multisystem involvement in neuromyelitis
optica. Ann Indian Acad Neurol 2015;18, Suppl S1:56-8
• Int J Neurosci. 2016 Oct;126(10):863-6. Epub 2015 Nov 19.
Mounting evidence suggests that NMO is distinct from classic relapsing-remitting multiple sclerosis with respect to pathogenesis, imaging features, biomarkers, neuropathology, and response to treatment.
involve multiple spinal cord segments and the optic nerves with associated axonal loss, perivascular lymphocytic infiltration, and vascular proliferation.
Whereas multiple sclerosis is mostly a cell-mediated disorder
such as plasmapheresis and intravenous immunoglobulin
as the initial presentation of NMOSDs in the absence of a history of AM or ON, and this may mimic acute brainstem infarction, Bickerstaff encephalitis and even Guillain-Barre´ syndrome
The possibility of a direct or indirect connection between these two immune-mediated disorders was also proposed
CSF testing should be reserved for patients where a high index of suspicion for an NMOSD remains despite negative serological evaluation
IVIG has not been specifically evaluated for ON/LETM relapses of NMO/NMO spectrum disorders and is rarely used for corticosteroid-refractory attacks