Aggressive Course of Myelin Oligodendrocyte Glycoprotein Antibody-Associated Disease (MOGAD): An Illustration of Two Cases and Review of Literature

Abstract

Myelin oligodendrocyte glycoprotein antibody-associated disease (MOGAD) is a central nervous system demyelinating disease that has become a major source of morbidity among children and adults. In the first case, we present an 18-year-old Hispanic female with a recently resolved upper respiratory infection who presented with fever, headache, progressive quadriparesis, urinary retention, and encephalopathy. The hospital course involved autonomic dysfunction and prolonged intubation requiring tracheostomy and gastrostomy. Cerebrospinal fluid (CSF) showed pleocytosis and a positive MOG titer (1:40). Magnetic resonance imaging (MRI) showed longitudinally extensive cervicothoracic T2 hyperintensity and brain multifocal T2 hyperintensities. After high-dose intravenous methylprednisolone (IVMP) and intravenous immunoglobulin (IVIG), she had full neurological recovery by the last follow-up. The second case is of a 22-year-old Hispanic male who presented with progressive lower extremity paresthesia and weakness over six weeks. CSF demonstrated pleocytosis, elevated protein, oligoclonal bands, and MOG antibody. MRI revealed multiple subcortical T2-hyperintense lesions and enhancing midcervical and lower thoracic lesions. Treatment with IVMP led to minor improvement with discharge on steroid taper and azathioprine. The patient's disease progressed with a fluctuating course requiring two readmissions with upper extremity weakness, right optic neuritis, and urinary sphincteric dysfunction with neuroradiologic worsening. Treatment throughout multiple admissions included intravenous steroids, IVIG, plasmapheresis, mycophenolate mofetil, and rituximab with minimal improvement, symptom recurrence, and progression of multifocal lesions. The patient died four months after the symptom onset. These cases had markedly different treatment responses despite similar baseline characteristics. The difference in morbidity and disability burden highlights the importance of further investigation of this condition through clinical trials.

Keywords: acute disseminated encephalomyelitis (adem); cns inflammatory demyelinating disease; cns inflammatory disorders; demyelinating autoimmune diseases; myelin oligodendrocyte glycoprotein antibody-associated disease (mogad); myelin-oligodendrocyte glycoprotein (mog); myelin-oligodendrocyte glycoprotein antibody-associated disease.

Figure 1. MRI brain and cervical spine from Case 1 at initial presentation.

FLAIR MRI, axial view, showing subcortical frontal hyperintense foci (A); T2 MRI, axial view, of cervical spine showing hyperintense grey matter, H-sign (B); FLAIR MRI, axial view, showing left midbrain involvement (C); and T2 MRI, sagittal view, of cervical spine, arrow showing hyperintense cord signal (D). Interval resolution of T2-hyperintense lesions on subcortical frontal lobes (E), cervical spine (F), midbrain (G), and cervical spine on follow-up imaging three months later (H). MRI: magnetic resonance imaging; FLAIR: fluid-attenuated inversion recovery image

Figure 2. MRI brain and spine from Case 2 at initial presentation to our service.

FLAIR MRI, axial view, showing T2-hyperintense lesions involving left caudate (A), right frontal corona radiata (B), left temporal lobe (C), right frontal lobe (D), and right optic nerve sheath (E). T2/short-tau inversion recovery MRI, sagittal view, showing T2-hyperintense conus medullaris (F). Sagittal cervical spinal cord with T2-hyperintense signal (G), associated with enhancing signal on sagittal T1 post-contrast (H). T2 MRI, coronal view, showing right optic nerve hyperintense rim (I). T2 MRI, axial view, showing T2 hyperintensity on right optic nerve sheath (J). MRI: magnetic resonance imaging; FLAIR: fluid-attenuated inversion recovery image