Wingerchuk et al, Neurol, 2006

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1 Current Understanding of Neuromyelitis Optica Jacqueline A. Leavitt, M.D. Mayo Clinic Rochester, MN I have no financial disclosures 46 y/o F Pain in R temple worse with head movements, resolved in days Film over R eye, thought to be sinus or allergy related Vision no better in weeks, sent to ER 1

2 Optic Neuritis Right Eye Va HM with 4+ RAPD Optic nerve full Rx with 3 day IVMP No changes in vision Optic Neuritis Right Eye MRI right side of chiasm full and enhances MRI 3 months later resolution of chiasmal changes Optic Neuritis Right Eye PMH: Jaundice age 18 DX: autoimmune hepatitis TX: Prednisone, then plaquenil added Azathioprine added later Age 36 prednisone and plaquenil DC d 2

Optic Neuritis Right Eye Nine months later Va 20/400 right eye, 20/20 left eye Color Va 1/13 right eye, 13/13 left eye No nystagmus or INO Pallor of Right optic disc Optic Neuritis Right Eye Central

3 Optic Neuritis Right Eye Nine months later Va 20/400 right eye, 20/20 left eye Color Va 1/13 right eye, 13/13 left eye No nystagmus or INO Pallor of Right optic disc Optic Neuritis Right Eye Central scotoma Foveal threshold 21 VF normal Left eye Optic Neuritis Right Eye Workup Normal/neg: CBC, coag, SPEP, ACE, ANCA, ANA, paraneoplastic panel, syphilis, Lyme, antiphospholipids Spinal tap: G 43, P 52, cells 3, OCB 0 MRI brain and orbits normal NMO Ab POSITIVE 3

4 Outline What is neuromyelitis optica (NMO)? How is NMO distinct from MS? What is the evidence for humoral autoimmunity? Novel, specific serological marker Outline What is neuromyelitis optica (NMO)? How is NMO distinct from MS? What is the evidence for humoral autoimmunity? Novel, specific serological marker Neuromyelitis Optica Uncommon idiopathic inflammatory demyelinating syndrome of the CNS Preferentially affects optic nerves (optic neuritis) and spinal cord (myelitis) 4

5 NMO Newest Diagnostic Criteria Absolute criteria Optic neuritis Acute myelitis Supportive criteria 2 of 3 Negative brain MR at disease onset Spinal cord MR with contiguous T2 abn > 3 vertebral segments NMO-IgG + Wingerchuk et al, Neurol, 2006 Outline What is neuromyelitis optica (NMO)? How is NMO distinct from MS? What is the evidence for humoral autoimmunity? Novel, specific serological marker NMO is Distinct from MS Natural history Severity MRI findings Cerebrospinal fluid analysis Systemic autoimmunity Autoantibody marker Treatment response 5

6 NMO is Distinct from MS Natural History Monophasic or relapsing Poor recovery with each successive attack > 50% of relapsing pts are legally blind and cannot walk unassisted within 5 years 20% die from neurogenic respiratory failure NMO is Distinct from MS Severity More severe attacks Greater residual deficits Simultaneous bilateral optic neuritis Complete, near-symmetric transverse myelitis NMO is Distinct from MS Demographics Non-Caucasian ethnicity Geographic distribution Sub-Saharan Saharan Africa China and Japan Ocular attacks more in African origin pts; Medullary attacks more in white pts Patients older than MS Merle et al, Ophth,

7 NMO Optic Neuritis More severe than MS Complete vision loss, pain with EOMs, incomplete recovery typical Bilateral simultaneous ON hallmark of NMO, rare in MS Typically 2 attacks lead to loss of vision NMO Transverse Myelitis Rapidly progressive paraparesis or quadraparesis, loss of sensation below the site of inflammation, bladder/bowel retention or incontinence Neck/back pain below lesion L hermitte s sign Repetitive painful limb spasms in > 50% NMO Other Presentations Intractable hiccups Persistent vomiting Encephalopathy Massive hemisphere lesions Thornton et al, Seminar Ophth,

NMO is Distinct from MS Brain MRI Normal MRI or white

Lesions in hypothalamus, adjacent to 3 rd and 4 th

abnormal MRI, 10% with MS-like lesions Brain Lesions in

Arch Neurol 2006;63:390-396 Copyright restrictions may

8 NMO is Distinct from MS Brain MRI Normal MRI or white matter changes that do not meet MS diagnostic criteria Lesions in hypothalamus, adjacent to 3 rd and 4 th ventricles, brainstem, optic nerves, spinal cord 60% abnormal MRI, 10% with MS-like lesions Brain Lesions in NMO: Nonspecific and specific Pittock SJ et al. Arch Neurol 2006;63: Copyright restrictions may apply. NMO-typical Brain Lesions are in AQP4-rich Sites (Orange dots) CP

.. NMO is Distinct from MS Spinal Fluid Pleiocytosis > 50 x10 6 WBC/L or > 5 x 10 6 PMN/L Oligoclonal bands

9 NMO is Distinct from MS Spinal MRI Longitudinally extensive, expansive, enhancing lesion of the central cord Three or more vertebral lengths involved excludes MS by McDonald criteria A picture tells a thousand words... NMO is Distinct from MS Spinal Fluid Pleiocytosis > 50 x10 6 WBC/L or > 5 x 10 6 PMN/L Oligoclonal bands (OCB) in only 15-30% compared with 85% in MS No increase in IgG (% or index) unlike MS Nakashima et al. Neurology

10 NMO - MS Pathology Focal demyelination, inflammation, scar formation, axonal destruction similar in NMO and MS Intense perivascular response, prominent necrosis, cavitation distinguish NMO from MS Lucchinetti et al, Neurol Clin, 2005 Neuropathology of NMO LFB-PAS Myelin KiM1P Macrophages Vascular Hyalinization 10

Patterns of Ig Deposition IgM IgG Outline What is neuromyelitis

Multiple autoantibodies Neuropathology Response to plasma

Novel, specific serological marker Systemic autoimmunity Rare in

Sjogren s, SLE, RA, polymyositis, myasthenia 50% have several

11 Patterns of Ig Deposition IgM IgG Outline What is neuromyelitis optica (NMO)? What is the evidence for humoral autoimmunity? Multiple autoantibodies Neuropathology Response to plasma exchange IgG isotypes in CSF suggest less Th1 inflammation Novel, specific serological marker Systemic autoimmunity Rare in MS Common in NMO 25% have systemic autoimmune disease: thyroid, Sjogren s, SLE, RA, polymyositis, myasthenia 50% have several autoab: ANA, ENA, SSA, SSB Pittock et al, Neurology, 2006 Wingerchuk et al, MS,

12 Outline What is neuromyelitis optica (NMO)? What is the evidence for humoral autoimmunity? Multiple autoantibodies Neuropathology Response to plasma exchange and?rituximab IgG isotypes in CSF suggest relatively less Th1 inflammation Novel, specific serological marker NMO Autoantibody NMO-IgG Ab 73% sensitive, 91% specific to distinguish NMO from optic-spinal presentations of MS Target Ag is aquaporin-4 (AQP4) Is NMO-IgG cause of disease or simply a marker of disease?? Lennon et al, Lancet, 2004 NMO-IgG titer, serum 30,720 7,680 1, <60 Neuromyelitis optica and optic-spinal multiple sclerosis High risk syndrome Multiple sclerosis presenting with optic neuritis or myelitis Diagnostic category Classical multiple sclerosis Miscellaneous disorders 12

13 NMO Autoantibody IgG marker for NMO IgG staining pattern localizing to the blood-brain brain barrier, partly co-localizing with laminin ELISA 100% specific, 60% sensitive Quant flow cytom 77% sensitive Waters PJ et al, Neurol 2012 Aquaporin 4 1st water channel-specific autoab identified Component of dystroglycan protein complex in astrocytic foot processes at BBB Facilitates water transport Especially in stress situations (i.e. brain injury) Aquaporin 4 (AQP4) Most abundant CNS water channel High concentration: spinal cord, optic nerves, hypothalamus, periventricular regions AQP4 location consistent with immunopathology 13

14 NMO is Distinct from MS Treatment Immunomodulatory drugs NOT suggested Immunosuppressive therapy best treatment IVMP 1gm/d x 5 or more days Plasmapheresis for severe exacerbations or poor response to steroids Could the fact that virtually all patients with NMO have extensive Ab-mediated disease explain the high response rate to PLEX? NMO is Distinct from MS Treatment Azathioprine (+prednisone) Mycophenolate mofetil (+prednisone) Rituximab Mitoxantrone IVIG Cyclophosphamide 14

15 NMO Consider this diagnosis for ATYPICAL optic neuritis Vision doesn t recover better than 20/40 Bilateral optic neuritis in adult No response to steroids or interferon Presence of other autoimmune diseases The ABC s of When to Consider NMO Atypical MS African or Asian patient Bilateral optic neuritis Bad outcome Cord involvement Crummy response to MS meds References Nakashima et al. Neurology 2004; 62: Narikawa et al. J Neuroimmunol 2004; 149: Lennon et al. Lancet 2004; 364: Lennon et al. J Exp Med 2005; 202: Pittock SJ et al. Arch Neuro 2006; 63: Wingerchuk et al. Neurol, 2006; 66: Merle et al. Ophth, 2007 Thorton I et al. Seminar Ophth 2011; 26: Wingerchuk et al. MS 2012; 18: 5-10 Waters et al. Neuro 2012; 78:

Magnetic Resonance Imaging of Neuromyelitis Optica (Devic s Syndrome)

J Radiol Sci 2012; 37: 45-50 Magnetic Resonance Imaging of Neuromyelitis Optica (Devic s Syndrome) Chien-Chuan Huang Tai-Yuan Chen Tai-Ching Wu Yu-Kun Tsui Te-Chang Wu Wen-Sheng Tzeng Chien-Jen Lin Department