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Serum antibodies directed against myelin oligodendrocyte glycoprotein (MOG) are found in patients with acquired CNS demyelinating syndromes that are distinct from multiple sclerosis and aquaporin-4-seropositive neuromyelitis optica spectrum disorder. Based on an extensive literature review and a structured consensus process, we propose diagnostic criteria for MOG antibody-associated disease (MOGAD) in which the presence of MOG-IgG is a core criterion. According to our proposed criteria, MOGAD is typically associated with acute disseminated encephalomyelitis, optic neuritis, or transverse myelitis, and is less commonly associated with cerebral cortical encephalitis, brainstem presentations, or cerebellar presentations. MOGAD can present as either a monophasic or relapsing disease course, and MOG-IgG cell-based assays are important for diagnostic accuracy. Diagnoses such as multiple sclerosis need to be excluded, but not all patients with multiple sclerosis should undergo screening for MOG-IgG. These proposed diagnostic criteria require validation but have the potential to improve identification of individuals with MOGAD, which is essential to define long-term clinical outcomes, refine inclusion criteria for clinical trials, and identify predictors of a relapsing versus a monophasic disease course., Competing Interests: Declaration of interests BB has or will potentially receive financial compensation for consultancy effort for Novartis, Roche, UCB, Horizon Therapeutics, Biogen, and Immunic Therapeutics for advice on clinical trial design. BB is funded by the National Multiple Sclerosis Society, National Institute of Health, and has been previously funded by the Canadian Multiple Sclerosis Society. JLB has received research grants from Novartis, Mallinckrodt Pharmaceuticals, Alexion, and the National Institutes of Health, license fees from a US patent (2014/0170140); consulting fees from Horizon Therapeutics, Alexion, BeiGene Chugai Pharmaceutical, Genentech, Genzyme, Mitsubishi-Tanabe Pharma, Reistone Biopharma, Roche, and AbbVie; and serves on Data Safety Monitoring Boards for Roche, Genentech, and Clene Nanomedicine. RM reports personal fees from Horizon Therapeutics, Alexion, Roche, and UCB and non-financial support from Horizon Therapeutics, Merck, Biogen, and Roche, outside the submitted work. HJK received a grant from the National Research Foundation of Korea and research support from Aprilbio and Eisai; received consultancy and speaker fees from Alexion, Aprilbio, Altos Biologics, Biogen, Celltrion, Daewoong, Eisai, GC Pharma, HanAll BioPharma, Handok, Horizon Therapeutics (formerly Viela Bio), Kolon Life Science, Mdimune, Merck Serono, Mitsubishi Tanabe Pharma, Novartis, Roche, Sanofi Genzyme, Teva-Handok, and UCB; and is a co-editor for the Multiple Sclerosis Journal and an associated editor for the Journal of Clinical Neurology. FB has received research funding from the National Health and Medical Research Council (Australia), Multiple Sclerosis Research Australia, New South Wales Health, Novartis, and the University of Sydney (Sydney, NSW, Australia). She has received speaker honoraria from Novartis, Biogen, Merck, and Limbic Neurology, and has been on advisory boards for Merck and Novartis. She works at the University of Sydney and at the Children's Hospital at Westmead, Westmead, New South Wales, Australia, which offers MOG-IgG testing. EPF has served on advisory boards for Alexion, Genentech, and Horizon Therapeutics. He has received speaker honoraria from Pharmacy Times and royalties from UpToDate for a topic on MOGAD. He was a site primary investigator in a randomised clinical trial on inebilizumab in neuromyelitis optica spectrum disorder run by Horizon Therapeutics. He is principal investigator on an RO1 on MOG-IgG disease. He works at Mayo Clinic, Rochester, MN, USA, which offers commercial MOG-IgG testing but he receives no royalties from such testing. SR has received research funding from the National Health and Medical Research Council (Australia), the Brain Foundation (Australia), the Royal Australasian College of Physicians, and the University of Sydney. She was supported by an National Health and Medicine Research Council Neil Hamilton Fairley Early Career Fellowship (APP1141169) and is currently supported by an NHMRC Emerging Leadership (EL2) Investigator Grant (APP2008339). She serves as a consultant on an advisory board for UCB and Limbic Neurology, and has been an invited speaker for Biogen, Limbic Neurology, and Excemed. PW has received research grants from Euroimmun AG, Commonwealth Serum Laboratories Behring and patent royalties for antibody testing (W02010046716A1). He is the co-director of the Oxford Autoimmune Neurology Diagnostic Laboratory (Oxford University, Oxford, UK) where MOG-IgG1 autoantibodies are tested and both he and the University of Oxford receive royalties (for antibody tests for LGI1 and CASPR2, W02010046716A1). He has received honoraria or consulting fees from Biogen Idec, F Hoffmann La-Roche, Mereo BioPharma, Retrogenix, UBC, Euroimmun AG, University of British Columbia, and Alexion; and travel grants from the Guthy-Jackson Charitable Foundation. Work in the Oxford Autoimmune Neurology Diagnostic Laboratory is supported by the UK National Health Service Commissioning service for NMOSD. ST has received speaker and consulting fees from Biogen-Idec Argentina, Merck SA, Genzyme-Sanofi, Roche, Novartis Argentina, and Novartis Pharma. She serves as a consultant on an advisory board for Genentech-Roche. and Alexion Pharmaceuticals. JSG has grant or contract research support from the National Multiple Sclerosis Society, Biogen, and Octave Biosciences for work unrelated to the present project. She serves on a steering committee for a trial supported by Novartis. She has received speaker fees from Alexion and Bristol Myers Sqiuibb, and served on an advisory board for Genentech. TC has received compensation for consulting from Biogen, Novartis Pharmaceuticals, Roche, Genentech, and Sanofi Genzyme. She has received research support from the National Institutes of Health, National Multiple Sclerosis Society, US Department of Defense, EMD Serono, Guthy-Jackson Charitable Foundation, I-Mab Biopharma, Mallinckrodt Pharmaceuticals, Novartis, Octave Bioscience, Roche Genentech, The Sumaira Foundation, and Tiziana Life Sciences. AUB has received grant support from Moore Foundation, Clinical and Trnaslational Awards Program, German Federal Ministry of Education and Research (BMBF). He has been named as inventor on several patents and patent applications describing multiple sclerosis serological biomarkers, drug targets for remyelination therapy, marker-less motor function analysis, and retinal image analysis methods. He serves on the Observational Study Monitoring Board for CAVS-MS. He is cofounder, board member, and currently serving as secretary treasurer of IMSVISUAL. He is cofounder and holds stocks of technology startups Motognosis GmbH and Nocturne GmbH. Motognosis GmbH develops and sells systems for assessing motor dysfunction in patients with neurological disorders. Nocturne GmbH offers analysis services for retinal optical coherence tomography. Both companies' products and services are relevant for neurology in general, but not specific to MOGAD. CH reports grant support from the Medical Research Council, Multiple Sclerosis Society, and Vasculitis UK. She serves as a consultant to Novartis, Biogen, Roche, UCB, Viela Bio, and Sanofi. She participated on an independent data safety monitoring board for the Wellcome Trust. RN reports grant support from Multiple Sclerosis Research Foundation (Netherlands). He has participated on a data safety monitoring board or advisory board for EXCEL study (neurofibromatosis). He is board member of the Dutch Pediatric Neurology Society. LP has received speaker honoraria and travel grants from Biogen, and has consulted for Biogen, Novartis, and Sanofi. Her university holds a patent for her invention: Live cell based assay for detection of autoantibodies for NMOSD and related disorders (Indian patent number 202141055841). MR is supported by research grants from the Austrian Science Fund (FWF project P32699), the Austrian Research Promotion Agency, Euroimmun, and Roche, and consulting fees and advisory board from Roche (to institution). MR works at the Clinical Department of the Medical University of Innsbruck (Innsbruck, Austria), which offers diagnostic testing for MOG-IgG and other autoantibodies. AS received personal compensation for consulting, serving on a scientific advisory board, speaking activities with Merck, Sanofi, Biogen, Roche, TEVA Pharmaceuticals, Novartis, Alexion, and Janssen. DKS has received research support from National council for Scientific and Technological Development CNPq Brazil (425331/2016-4 and 308636/2019-8), Fundacao de Amparo Pesquisa do Estado do Rio Grande do Sul (17/2551-0001391-3 and 21/2551-0000077-5), TEVA Pharmaceuticals, Merck, Biogen, and Euroimmun AG; speaker honoraria from Biogen, Novartis, Genzyme, TEVA Pharmaceuticals, Merck, Roche, and Bayer; and participates in advisory boards for Biogen, Roche, and Merck. KR has been an invited speaker for Merck and serves as a consultant for an advisory board for Roche. FP has received honoraria and research support from Alexion, Bayer, Biogen, Chugai, MerckSerono, Novartis, Genyzme, MedImmune, Shire, and Teva Pharmaceuticals, and serves on scientific advisory boards for Alexion, MedImmune, Novartis, and UCB. He has received funding from Deutsche Forschungsgemeinschaft (DFG Exc 257), Bundesministerium für Bildung und Forschung (Competence Network Multiple Sclerosis), Guthy-Jackson Charitable Foundation, EU Framework Program 7, and National Multiple Sclerosis Society of the USA. He serves on the steering committee of the N-Momentum study with inebilizumab (Horizon Therapeutics) and the OCTiMS Study (Novartis). He is an associatee editor with Neurology, Neuroimmunology, and Neuroinflammation and academic editor with PloS One. SJP reports grants, personal fees, and non-financial support from Alexion Pharmaceuticals; grants, personal fees, and non-financial support from MedImmune /Viela Bio; and personal fees for consulting from Genentech, Roche, UCB, and Astellas. He has two patents issued (8889102; application 12-678350; Neuromyelitis Optica Autoantibodies as a Marker for Neoplasia; and 9891219B2; application 12-573942; Methods for Treating Neuromyelitis Optica [NMO] by Administration of Eculizumab to an individual that is Aquaporin-4 [AQP4]-IgG Autoantibody positive). SJP also has patents pending for IgGs to the following proteins as biomarkers of autoimmune neurological disorders: septin-5, kelch-like protein 11, GFAP, PDE10A, and MAP1B. He works at Mayo Clinic, which offers commercial MOG-IgG testing. He receives no royalties from the sale of tests done at the neuroimmunology Laboratory at Mayo Clinic. KF serves as an advisor or on scientific advisory boards for Biogen, Mitsubishi Tanabe, Novartis, Chugai, Roche, Alexion, VielaBio/Horizon Therapeutics, UCB, Merck Biopharma, Japan Tobacco and Abbvie; has received funding for travel and speaker honoraria from Biogen, Eisai, Mitsubishi Tanabe, Novartis, Chugai, Roche, Alexion, VielaBio, Teijin, Asahi Kasei Medical, Merck, and Takeda; and has received the Grants-in-Aid for Scientific Research from the Ministry of Education, Culture, Sports, Science and Technology of Japan and the Grants-in-Aid for Scientific Research from the Ministry of Health, Welfare and Labor of Japan. JP has received consulting fees from Merck, Novartis, Roche, Mitsubishi Tnabe Pharma, UCB, Alexion, Vitaccess, and Argenx, and MRI support from Medimmune, Merck, and Roche. She has received payment or honoraria for lectures, presentations, speakers bureaus, manuscript writing, or educational events from Merck, VielaBio, Roche and Alexion. She has participated on a data safety monitoring board or advisory board for Novartis, Roche, Argenx, UCB, Alexion, and Sanofi. She is member of the Charcot Foundation Board, Magnetic Resonance in Multiple Sclerosis steering committee, and National Health Service England Intravenous Immune Globulin Committee. She holds stock for AstraZeneca for a product that is not related to MOG-antibody associated disease. She has a patent for Diagnosing Multiple Sclerosis (application no PCT/GB2013/050285, final patent number 13704627.2–1408; client reference 4440; MS reference P37347WO; patent published Sept 13, 2021)., (Copyright © 2023 Elsevier Ltd. All rights reserved.) more...

Background: Optic neuritis (ON) is the most prevalent manifestation of pediatric multiple sclerosis (MS ped ) and myelin-oligodendrocyte glycoprotein antibody-associated disease (MOGAD ped ) in children > 6 years. In this study, we investigated retinal atrophy patterns and diagnostic accuracy of optical coherence tomography (OCT) in differentiating between both diseases after the first ON episode., Methods: Patients were retrospectively identified in eight tertial referral centers. OCT, VEP and high/low-contrast visual acuity (HCVA/LCVA) have been investigated > 6 months after the first ON. Prevalence of pathological OCT findings was identified based on data of 144 age-matched healthy controls., Results: Thirteen MOGAD ped (10.7 ± 4.2 years, F:M 8:5, 21 ON eyes) and 21 MS ped (14.3 ± 2.4 years, F:M 19:2, 24 ON eyes) patients were recruited. We observed a significantly more profound atrophy of both peripapillary and macular retinal nerve fiber layer in MOGAD ped compared to MS ped (pRNFL global: 68.2 ± 16.9 vs. 89.4 ± 12.3 µm, p < 0.001; mRNFL: 0.12 ± 0.01 vs. 0.14 ± 0.01 mm 3 , p < 0.001). Neither other macular layers nor P100 latency differed. MOGAD ped developed global atrophy affecting all peripapillary segments, while MS ped displayed predominantly temporal thinning. Nasal pRNFL allowed differentiation between both diseases with the highest diagnostic accuracy (AUC = 0.902, cutoff < 62.5 µm, 90.5% sensitivity and 70.8% specificity for MOGAD ped ). OCT was also substantially more sensitive compared to VEP in identification of ON eyes in MOGAD (pathological findings in 90% vs. 14%, p = 0.016)., Conclusion: First MOGAD-ON results in a more severe global peripapillary atrophy compared to predominantly temporal thinning in MS-ON. Nasal pRNFL allows differentiation between both diseases with the highest accuracy, supporting the additional diagnostic value of OCT in children with ON., (© 2022. The Author(s).) more...

Background: To investigate age-related severity, patterns of retinal structural damage, and functional visual recovery in pediatric and adult cohorts of myelin oligodendrocyte glycoprotein antibody-associated disease (MOGAD) optic neuritis (ON)., Methods: All MOGAD patients from the 5 participating centers were included. Patients with initial manifestation <18 years were included in the pediatric (MOGAD ped ) cohort and patients with ≥18 years in the adult (MOGAD adult ) cohort. For patients with MOGAD ON, examinations at least ≥6 months after ON onset were included in the analyses. Using spectral domain optical coherence tomography (SD-OCT), we acquired peripapillary retinal nerve fiber layer thickness (pRNFL) and volumes of combined ganglion cell and inner plexiform layer (GCIPL). High- and 2.5% low-contrast visual acuity (HCVA, LCVA) and visual-evoked potentials (VEP) were obtained., Results: Twenty MOGAD ped (10.3±3.7 years, 30 MOGAD ON eyes) and 39 MOGAD adult (34.9±11.6 years, 42 MOGAD ON eyes) patients were included. The average number of ON episodes per ON eye was similar in both groups (1.8±1.3 and 2.0±1.7). In both pediatric and adult MOGAD, ON led to pronounced neuroaxonal retinal atrophy (pRNFL: 63.1±18.7 and 64.3±22.9 μm; GCIPL: 0.42±0.09 and 0.44±0.13 mm 3 , respectively) and moderate delay of the VEP latencies (117.9±10.7 and 118.0±14.5 ms). In contrast, visual acuity was substantially better in children (HCVA: 51.4±9.3 vs. 35.0±20.6 raw letters, p=0.001; LCVA: 22.8±14.6 vs. 13.5±16.4, p=0.028). Complete visual recovery (HCVA-logMAR 0.0) occurred in 73.3% of MOGAD ped and 31% MOGAD adults ON eyes, while 3.3% and 31% demonstrated moderate to severe (logMAR > 0.5) visual impairment. Independent of retinal atrophy, age at ON onset significantly correlated with visual outcome., Conclusion: Pediatric MOGAD ON showed better visual recovery than adult MOGAD ON despite profound and almost identical neuroaxonal retinal atrophy. Age-related cortical neuroplasticity may account for the substantial discrepancy between structural changes and functional outcomes. more...

We retrospectively evaluated predictors of conversion to multiple sclerosis (MS) in 357 children with isolated optic neuritis (ON) as a first demyelinating event who had a median follow-up of 4.0 years. Multiple Cox proportional-hazards regressions revealed abnormal cranial magnet resonance imaging (cMRI; hazard ratio [HR] = 5.94, 95% confidence interval [CI] = 3.39-10.39, p < 0.001), presence of cerebrospinal fluid immunoglobulin G oligoclonal bands (OCB; HR = 3.69, 95% CI = 2.32-5.86, p < 0.001), and age (HR = 1.08 per year of age, 95% CI = 1.02-1.13, p = 0.003) as independent predictors of conversion, whereas sex and laterality (unilateral vs bilateral) had no influence. Combined cMRI and OCB positivity indicated a 26.84-fold higher HR for developing MS compared to double negativity (95% CI = 12.26-58.74, p < 0.001). Accordingly, cerebrospinal fluid analysis may supplement cMRI to determine the risk of MS in children with isolated ON., (© 2015 American Neurological Association.) more...

Background: Some pediatric patients with inflammatory demyelinating central nervous system disorders cannot be classified under any of the established disease entities, making their treatment and prognosis difficult., Objective: The objective of this study is to characterize a subgroup of pediatric patients with recurrent demyelinating central nervous system disorders., Methods: This study includes a case series of pediatric patients with monophasic or recurrent acute disseminated encephalomyelitis (ADEM) who later presented with either monophasic or recurrent optic neuritis (ON)., Results: We describe seven patients with a median follow-up of six years (five females, two males) who presented at a median age of 6 years (range 4-8 years) with monophasic (n = 4) or recurrent ADEM (two to four attacks) followed by monophasic (n = 3) or recurrent ON (two to nine attacks). Cranial magnetic resonance imaging (MRI) was typical for ADEM (n = 6) with complete or almost complete resolution of lesions on follow-up. Cerebrospinal (CSF) studies at the time of ADEM showed a pleocytosis in six patients and were negative for oligoclonal bands (OCBs) in all. In all patients high titers for serum anti-MOG antibodies were detected., Conclusion: ADEM followed by ON is a rare but distinct clinical phenotype among pediatric patients. Further studies are needed to allow recommendations on treatment or prognosis. more...

Objective: To study the humoral immune response directed at myelin oligodendrocyte glycoprotein (MOG)in pediatric patients with isolated and recurrent optic neuritis(ON)., Design: Observational prospective case series., Setting: Six pediatric hospitals in Germany and Austria., Patients: Thirty-seven patients 18 years or younger with single or recurrent episodes of ON were recruited from 6 different hospitals., Main Outcome Measures: Clinical features, magnetic resonance imaging findings, intrathecal IgG synthesis,and outcome were recorded. A live cell–based immunofluorescence assay was used to measure serum IgG antibodies to MOG and aquaporin 4., Results: A single episode of ON was observed in 10 patients,and 15 experienced 2 to 12 episodes. The acute episode of ON was part of a clinically isolated syndrome in 12 patients, of whom 8 were subsequently classified as having multiple sclerosis. High-titer serum MOG-IgG antibodies (1:160) were detected in 17 patients (46%).In addition, high titers of MOG-IgG antibodies were more frequently observed in 12 of the 15 patients with recurrent episodes of ON (80%; median titer, 1:640)compared with 2 of the 10 patients with monophasic ON(20%; median titer, 0) and 3 of the 12 patients with ON as part of a clinically isolated syndrome (25%; median titer, 0)., Conclusion: High-titer MOG-IgG antibodies are predominantly detected in pediatric patients with recurrent ON, indicating that anti-MOG-specific antibodies may exert a direct role in the pathogenesis of ON in this subgroup. more...

It has been suggested that Chlamydia pneumoniae (C. pneumoniae) is involved in the pathogenesis of diverse diseases of the central nervous system (CNS), including multiple sclerosis. We report the case of a 12-year-old male with isolated recurrent optic neuritis and an associated CNS infection with C. pneumoniae. The patient presented with three attacks of optic neuritis within 5 months. A positive polymerase chain reaction for C. pneumoniae in the cerebrospinal fluid led to the diagnosis of a CNS infection with C. pneumoniae. After treatment with the antibiotic rifampicin, he experienced no further attacks during the follow-up period of 6 years. These findings suggest the possibility of a C. pneumoniae infection as a contributing factor or even causative event for the development of optic neuritis. more...