Case Study: Intravenous Immunoglobulin Can Treat Myelin Oligodendrocyte Glycoprotein Antibody-Associated Optic Neuritis in Pediatric Population

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Intravenous immunoglobulin was found to be the most effective immunotherapy in preventing relapses after treatment with steroids in pediatric patients.

Intravenous immunoglobulin (IVIG) therapy can be used to effectively treat myelin oligodendrocyte glycoprotein antibody (MOG-Ab)-associated optic neuritis in pediatric patients, according to a case study published in Cureus.

Image credit: Naeblys - stock.adobe.com

Image credit: Naeblys - stock.adobe.com

One of the most common forms of acquired demyelinating syndromes in childhood, optic neuritis presents as unilateral or bilateral vision changes, and is often associated with pain. Recurrent episodes of optic neuritis can lead to chronic relapsing inflammatory optic neuropathy (CRION), and optic neuritis with MOG-Ab seropositivity may present with neurological or systemic symptoms, according to the study.

Investigators analyzed a case of an 8-year-old boy to gain a better understanding of the full spectrum of phenotypes and best treatment options available for MOG-Ab associated disorders.

The boy presented with complaints of headaches for 2 weeks and blurry vision in his left eye for 2 days, in addition to a pain when moving his left eye. An MRI of the brain and orbit revealed an edematous left optic nerve displaying pronounced enhancement, which was indicative of optic neuritis.

Treatment providers started the child on a high dose of 30 mg/kg of methylprednisolone for 5 days, with a gradual tapering over 2 weeks. Significant improvement was reported in the child’s vision following the start of steroid therapy. However, 1 month after the initial presentation, the child returned with similar complaints of blurry vision and eye pain, suggesting a relapse.

An MRI of the brain confirmed the presence of right optic neuritis, showing an enhancement of the right optic nerve. Additionally, his pattern visual evoked potentials displayed an abnormal cortical response on the right and a recovery of latency responses in the left optic pathway.

Once again, the child was treated with methylprednisolone pulse therapy of 30 mg/kg for 5 days, which resulted in a complete recovery of his symptoms. Anti-MOG-Ab results returned positive, with a titer of 1:100. The decision was made by his treatment providers to initiate monthly IVIG infusion therapy as a disease-modifying intervention.

The child tolerated and responded well to the treatment, and after 1 year, a repeat of his anti-MOG-Ab titer was still positive with a titer of 1:100. He experienced no clinical relapses, and his IVIG therapy was gradually spaced out over the second year. The child continues to receive regular quarterly infusions of IVIG, and there have been no relapses thus far over 2 years.

Anti-MOG-Ab is associated with a large spectrum of clinical presentations and is linked to both monophasic and relapsing forms of acute disseminated encephalomyelitis (ADEM), transverse myelitis, and optic neuritis.

Recent studies have linked the syndrome more closely with optic neuritis. MOG-Ab-associated optic neuritis tends to have greater involvement of the anterior optic pathways while sparing the optic chiasm and optic tracts, as the case study shows, the investigators wrote.

Furthermore, optic disk edema was observed to be more prevalent in MOG-Ab-associated optic neuritis in comparison to other demyelinating Abs. Additionally, children with optic neuritis who were seropositive for anti-MOG-Abs demonstrated a better recovery compared to the seronegative ones.

The investigators discussed the importance of assessing for anti-MOG-Abs in a child presenting with acute vision changes, so that a quick diagnosis can be made and treatment can be initiated.

Current treatment methods for anti-MOG-Ab-positive optic neuritis are aimed toward treating acute presentation and reducing the chances of relapses; however, in the case of a relapse, the decision to begin regular immunotherapy is considered based on individual factors of the patient, the researchers discussed.

Many recent studies have indicated that relapse rates are significantly reduced with maintenance immunotherapy, and a recent retrospective study conducted by Chen et al. showed that IVIG maintenance therapy was most effective with fewer adverse effects among all possible agents in the reduction of relapse rate per year. The researchers reaffirmed this in their study, as no relapses have occurred on IVIG maintenance therapy, they wrote.

Reference

Kadam R, Fathalla W, Hosain SA, et al. A case of myelin oligodendrocyte glycoprotein antibody-associated optic neuritis responsive to intravenous immunoglobulin (IVIG) therapy in a pediatric patient. Cureus. 2023;9(15)(8):e43218. doi:10.7759/cureus.43218

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