095\u2005‘No End in Sight’, Management dilemma of refractory MOG antibody positive optic neuritis

Abstract

Background The patient is a 38-year-old lady who presented with impaired visual acuity in her right eye which was accompanied with pain on extra-ocular movements. Her symptoms initially resolved with high dose steroid therapy. This is on a background of eosinophilic asthma which is refractory to maximal inhaler therapy and IL-5 monoclonal antibody therapy. Methods/Results The patient had unremarkable blood results and inflammatory makers and a normal CSF study. She was subsequently found to be myelin oligodendrocyte glycoprotein (MOG) antibody positive but negative for (Aquaporin -4) AQP-4 antibodies. Radiological findings on MRI of the brain and spine was suggestive of multiple sclerosis (MS). Whilst receiving intravenous immunoglobulin (IVIG) as a bridging therapy to Multiple Sclerosis (MS) modifying therapy, the patient developed severe adverse reaction to IVIG with desquamation of her hands and legs. Furthermore, she did not achieve satisfactory disease control with Ocrelizumab. Has cushingoid features secondary to long term high dose steroid therapy. Conclusions To highlight the challenges and difficulty in managing a patient with refractory MOG antibody optic neuritis and its impact on the quality of life of the patient. To demonstrate the gap in available clinical evidence in the management of recurrent MOG antibody positive optic neuritis. To initiate an open discussion regarding the treatment of these challenging group of patients References Chen JJ, Tobin WO, Majed M, Jitprapaikulsan J, Fryer JP, Leavitt JA, Flanagan EP, McKeon A, Pittock SJ. Prevalence of myelin oligodendrocyte glycoprotein and aquaporin-4-IgG in patients in the optic neuritis treatment trial. JAMA ophthalmology 2018;136(4):419–422. Chen JJ, Flanagan EP, Bhatti MT, Jitprapaikulsan J, Dubey D, Lopez Chiriboga ASS, Fryer JP, Weinshenker BG, McKeon A, Tillema J-M, Lennon VA, Lucchinetti CF, Kunchok A. Steroid-sparing maintenance immunotherapy for MOG-IgG associated disorder. Neurology 2020;95(2):e111–e120.