To be specific, if a patient has bilateral optic neuritis with positive NMO IgG and asymptomatic spinal cord lesions > 3 segments, is it NMO or NMOSD?
I think that a patient who has spinal cord lesions> 3 segments will present with symptoms attributed to his/her myelitis... If that patient without myelitis symptoms exists,,, it is very interesting.
Indeed it is unusual. This patient on presentation didnot have any features of myelopathy and was managed as NMOSD. She was managed with immunosuppressants but after 4 months she developed spasticity in all 4 limbs and downbeating nystagmus. Now she satisfied the criteria of NMO. Similar case of subclinical optic neuropathy has been reported before in 'J Neuro-Ophthalmol 2013; 33: 202-207'. This may be showing the pitfall in the wingerchuck criteria for NMO.
It is not clear to me if antibodies against aqp4 were found in this patient. Woudl you mind to clarify?
Hi Francesco roselli... Yes NMO IgGwas positive in the initial presentation itself
Sygkliti Henrietta Pelidou
To my opinion, yes it could be possible subclinical myelopathy to be a feature of NMO/NMOSD, as well as subclinical Optic Neuritis (detected by VEPs or OCT), without clinical history of ON.
I would be surprised if a patient with bilateral optic neuritis and positive NMO IgG had asymptomatic spinal cord lesions > 3 segments. In fact I have two patients with bilateral optic neuritis and positive NMO IgG that have mild pyramidal signs and symptoms. The first has no visible spinal cord lesions on a 3 T MRI 3 years now and the second has two small lesions, one cervical and one thoracic. In both patients the onset of symptoms of myelopathy was insidious.
Sygkliti- Henrietta Pelidou
Hello everybody!
Do you think that the wingerchuck criteria for NMO have to be revised?
A patient with bilateral ON and positive NMO Ab should be treated as NMO, or we should wait for clinical/MRI features of myelitis?
In fact, I have seen a patient with ON and high titers of NMO, which relapse came 4 years after severe myeliis. The patient was left wheelchair bound and she was on no spesific therapy after myelitis. I was wondering if she was on B cell depletion therapy or immunosupressive therapy could this relapse be avoided?
Hello,
I agree with your statement and would treat a patient with bilateral ON and positive NMO ab as NMO. Even if she had only bilateral ON, the risk of permanent blindness is too great if we leave her without specific NMO treatment.
Hello,
I also agree. This patient has NMO...plasmapheresis could help to delete the NMOIg
I think any patient with bilateral optic neuritis or long segment demyelination with NMO IgG should be considered as NMO and treated with immunomodulation. Its time to take a relook at wingerchuk criteria.
I agree. It is NMO. Need to start therapy for clinical symptoms and plasmapheresis
AQP4 Antibody may be detectable in earlier cases and to decide start trt.
In the first place a patient with NMO IgG positive and bilateral OPN is definitely part of the NMOSD and should be treated long term with immunosupression. However myelitis in NMO is unlikely to be asymptomatic. They are lengthy tumifactive lesions and will not remain silent.
hELLO TRERE!
I TOTALLY AGREE WITH LEKHA PANDIT!
EITHER WITH Optic Neuritis OR Tranverse Myelitis ONLY PLUS POSITIVE nmo AB WE MUST TREAT PATIENTS IN ORDER TO PREVENT SUBSEQUENT EVOLUTION OF THE NMO CLINICAL PHENOTYPE.
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