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Anti‐myelin oligodendrocyte glycoprotein antibody neuritis optica following anti‐NMDA receptor encephalitis

A 9-year-old girl was admitted to hospital with fever, somnolence, hemiplegia, dysphagia, and memory impairment. Cellbased assay indicated that she was positive for anti-N-methylD-aspartate receptor (anti-NMDAR) antibodies in serum and cerebrospinal fluid (CSF). On brain magnetic resonance imaging (MRI) T2-weighted (T2)/fluid-attenuated inversion recovery, abnormality was noted in the left temporal and parietal lobes (Fig. 1). Electroencephalogram demonstrated slowing of the background rhythm in the left cerebral hemisphere, but no epileptiform discharge. On lumbar puncture, 44 white blood cells had mixed cellularity and protein was 22 mg/dL. Bacterial culture and tests for various viruses were negative. Oligoclonal IgG band and anti-aquaporin-4 antibody (AQP4) were not present. The patient had no ophthalmologic abnormalities or associated tumors; she was therefore diagnosed with antiNMDAR encephalitis and treated with three courses of pulse i.v. methylprednisolone (IVMP) and i.v. gammaglobulin (IVIG). She was symptom free at discharge and was treated with oral prednisolone (gradually tapered over 5 months). Seventeen days after cessation of prednisolone, she was readmitted due to right visual impairment, pain, and headache. The right optic disc was swollen, she had a reduced light reflex and could discern hand movement but nothing else through the right eye. Visual acuity in the left eye was intact. Brain MRI indicated contrast enhancement in the right optic nerve, but no abnormality in the cerebral hemisphere or spinal cord (Fig. 2). Serum and CSF were strongly positive for antimyelin oligodendrocyte glycoprotein (anti-MOG) antibodies, but negative for anti-AQP4 and anti-NMDAR antibodies. There was no oligoclonal IgG band. Myelin basic protein in the CSF was elevated (149 pg/mL, standard value, <102). She was diagnosed with anti-MOG antibody-positive neuromyelitis optica spectrum disorder (NMOSD) and treated with three courses of IVMP and IVIG. Visual acuity at discharge was normal. On re-testing of stocked serum, anti-MOG antibodies were positive at the same time that symptoms of anti-NMDAR encephalitis were evident. At 18 months after initial presentation, she received oral prednisolone (5 mg/day). Anti-NMDAR encephalitis is an immune-mediated disorder associated with IgG antibodies against the GluR1 subunit of NMDAR. It is very difficult to distinguish anti-NMDAR encephalitis from acute disseminated encephalomyelitis. Thus, further investigation of NMDAR antibody level is needed to facilitate diagnosis. Neuromyelitis optica (NMO) and NMOSD are autoimmune inflammatory disorders of the central nervous Fig. 1 T2/fluid-attenuated inversion recovery-weighted magnetic resonance imaging the brain showing high signal intensity in the left temporal and parietal lobes.