Myelin-Oligodendrozyten-Glykoprotein-Antikörper bei Neuritis nervi optici im Kindesalter

Zusammenfassung

Hintergrund Myelin-Oligodendrozyten-Glykoprotein (MOG) ist an der Oberfläche der Myelinscheiden und der Oligodendrozyten im Zentralnervensystem lokalisiert. Im Kindes- und Erwachsenenalter zeigt sich eine Assoziation von MOG-AK im Serum mit rezidivierender und bilateraler Neuritis nervi optici (NNO), mit akuter disseminierter Enzephalitis (ADEM) und mit transverser Myelitis (TM). Die Kombination von NNO mit TM oder anderen entzündlichen Hirnläsionen ist typisch für eine Neuromyelitis-optica-Spektrum-Erkrankung (NMO-SD), die mit hochspezifischen pathogenen Aquaporin-4-IgG-Autoantikörpern (AQP4-AK) im Serum assoziiert ist. Kinder mit NMO-SD sind häufig seronegativ für AQP4-AK, aber seropositiv für MOG-AK. Krankheitsverlauf und Therapie der NNO bei Kindern mit NNO-positiven MOG-AK sind deshalb von besonderem Interesse.

Patienten Die Krankheitsverläufe von 2 8-jährigen Jungen mit akuter NNO werden dargestellt (bilaterale NNO, AQP4-AK negativ, MOG-AK positiv). Patient 1 erlitt trotz immunsuppressiver Therapie mehrere Rezidive bei persistierenden MOG-AK mit zunehmender Optikusatrophie, erheblicher einseitiger Visusminderung und passagerer Hirnstammbeteiligung. Bei Patient 2 liegt ein bisher monophasischer Verlauf mit raschem Abfall der MOG-AK und nur geringer asymmetrischer Optikusatrophie vor.

Diskussion MOG-AK sind im Kindesalter mit rezidivierender NNO und Hirnläsionen assoziiert, die typisch für eine ADEM oder eine NMO-SD sind. In der akuten Phase der klinischen Symptomatik werden hohe MOG-AK-Titer beobachtet. Rezidive der NNO führen zu einem zunehmenden Verlust der retinalen Nervenfaserschicht. Diagnostisch sind die Antikörperbestimmung (AQP4-AK, MOG-AK) sowie eine MRT-Bildgebung obligat. Als therapeutische Schlussfolgerung ergibt sich daraus die Notwendigkeit einer konsequenten Behandlung mit initial Kortikosteroiden und nachfolgender Immunsuppression (z. B. Azathioprin, Mycophenolat, bei refraktären Fällen auch Rituximab) sowie der Kontrolle der MOG-AK-Titer.

Abstract

Background Myelin oligodendrocyte glycoprotein (MOG) is located on the surface of oligodendrocytes and myelin in the central nervous system. MOG-IgG is associated with acute disseminated encephalomyelitis (ADEM), relapsing and bilateral optic neuritis (NNO), and transverse myelitis (TM) in both paediatric and adult patients. The combination of NNO and TM or other inflammatory brain lesions is a typical feature of neuromyelitis optica spectrum disorders (NMO-SD) which are associated with specific pathogenic autoantibodies against the water channel aquaporin-4 (AQP4-IgG). However, children with NMO-SD are often seronegative for AQP4-IgG but seropositive for MOG-IgG. Therefore, the course and therapy of MOG-IgG positive NNO in children were of special interest.

Patients The course of disease of two male patients with acute NNO is presented (bilateral NNO, age of onset 8 years each, AQP4-IgG negative, MOG-IgG positive). Several relapses of NNO occurred in patient 1 with persisting MOG-IgG in spite of immunsuppressive therapy. He suffered from increasing optic atrophy, considerable visual loss and transient brainstem affection. Patient 2 showed a monophasic course of disease with a rapid decline in MOG-IgG titre and only minor asymmetric optic atrophy.

Conclusions MOG-IgG in children is associated with recurrent NNO and cerebral lesions characteristic of ADEM or NMO-SD. High titres of MOG-IgG are observed during the acute phase of clinical symptoms. Relapses of NNO lead to increasing loss of retinal nerve fibre layer. Diagnostic investigation includes the determination of AQP4-IgG and MOG-IgG as well as magnetic resonance imaging (MRI) of brain and spinal cord. The therapeutic consequence of this is consistent immunsuppressive treatment, starting with intravenous steroids and followed by second-line therapy with steroid sparing immunosuppressants, including mycophenolate or azathioprine, followed in refractory cases by rituximab. The therapeutic effect should be controlled by laboratory tests of MOG-IgG titre.

Schlüsselwörter

Neuritis nervi optici - Myelin-Oligodendrozyten-Glykoprotein-Antikörper - Neuromyelitis-optica-Spektrum-Erkrankungen - Aquaporin-4-Antikörper - Kinder

Key words

optic neuritis - myelin oligodendrocyte glycoprotein antibodies - neuromyelitis optica spectrum disorders - aquaporin-4 antibodies - children

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