neuromyelitis optica spectrum disorder neuromyelitis optica spectrum disorder neuromyelitis optica spectrum disorders (nmosd), including neuromyelitis optica (nmo), are autoimmune diseases characterized by acute inflammation of the optic nerve (optic neuritis, on) and the spinal cord (myelitis). episodes of on and myelitis can be simultaneous or successive. a relapsing disease course is common, especially in untreated patients. in more than 80% of cases, nmo is caused by immunoglobulin g autoantibodies to aquaporin 4 (anti-aqp4), the most abundant water channel protein in the central nervous system. a subset of anti-aqp4-negative cases is associated with antibodies against myelin oligodendrocyte glycoprotein (anti-mog). rarely, nmo may occur in the context of other autoimmune diseases (e.g. connective tissue disorders, paraneoplastic syndromes) or infectious diseases. in some cases, the etiology remains unknown (idiopathic nmo). neuromyelitis optica spectrum disordersother namesneuromyelitis optica (nmo), devic's disease, devic's syndromespecialtyneurology, ophthalmologysymptomsvision loss, sensory loss, weakness, bladder dysfunctionusual onsetmedian: age 40 for aqp4-igg, age 31 for mog-iggtypesaqp4-igg-positive, mog-igg-positive (recurrent, monophasic)risk factorsfemale sex, genetic factorsdiagnostic methodsymptoms, blood antibody titers, mridifferential diagnosismultiple sclerosis, various autoimmune disordersmedicationeculizumab, inebilizumab, satralizumab, rituximab, methylprednisolone, azathioprine, cellcept, mitoxantrone, methotrexate, intravenous immunoglobulin, cyclophosphamidefrequencyup to 1 in 10,000 multiple sclerosis (ms) and nmo can be similar in clinical and radiological presentation, and ms may very rarely present with an nmo-like phenotype (e.g. in patients with long-standing ms resulting in confluent spinal cord lesions mimicking the long spinal cord lesions typically seen in ms). in consequence, nmo was in the past wrongly considered a clinical variant of ms. however, nmo is not related to ms in the vast majority of cases and differs from ms substantially in terms of pathogenesis, clinical presentation, magnetic resonance imaging, cerebrospinal fluid findings, disease course, and prognosis. signs and symptoms the signs and symptoms of nmosd depend on the neurologic structures the disease affects, and, to some extent, the antibodies involved. signs and symptoms usually follow a relapsing and remitting course, but occasionally can be progressive (monophasic). deficits can be temporary or permanent, the latter especially in the absence of treatment. the most common initial manifestation of the disease is inflammation of the spinal cord (myelitis). myelitis causes spinal cord dysfunction, which can result in muscle weakness, paralysis in the limbs, lost or reduced sensation, spasms, loss of bladder and bowel control, or erectile dysfunction. the myelitis can be transverse, affecting an entire cross-section of the spinal cord, and showing bilateral symptoms. the second most common initial manifestation of the disease is inflammation of the optic nerve and/or optic chiasm (optic neuritis, on). on may lead to varying degrees of visual impairment with decreased visual acuity, although visual field defects, or loss of color vision, may occur in isolation or prior to formal loss of visual acuity. compared to idiopathic on and on due to multiple sclerosis (ms), on due to nmosd more often results in severe visual loss at onset, with bilateral involvement, and permanent visual deficits. classically, nmo included only symptoms of myelitis and on. however, with the discovery of disease-causing antibodies, a broader spectrum of disease manifestations has been grouped with nmo into the diagnosis of nmosd. less commonly than the spinal cord and optic nerve, nmosd can affect the brain stem. lesions in the brain stem or upper cervical spinal cord can cause respiratory insufficiency. lesions in the area postrema of the medulla oblongata can cause vomiting or hiccups, as well as pain and tonic spasms. additional brain lesions are common but often asymptomatic (though cognitive deficits, as well as depression, may be underdiagnosed sequalae). lesions may also affect the diencephalon, mostly in aquaporin-4–immunoglobulin-g (aqp4-igg) nmosd. causes nmosd is caused by an autoimmune attack on the nervous system. in more than 80% of cases, igg autoantibodies against aquaporin-4 (anti-aqp4+) are the cause, and in 10–40% of the remaining cases, igg antibodies against mog are the cause. the cause of the remaining cases is still unknown, and it is likely heterogeneous. why autoimmunity develops is largely unknown. multiple genetic and environmental factors are known to increase the risk of developing nmosd. the strongest risk factor is being female, especially in aqp4-igg-positive nmosd. multiple human leukocyte antigen (hla) alleles are associated with nmosd. nmo was associated in the past with many systemic diseases. some researchers have pointed out that some other cases could be paraneoplastic. it appears that lupus can produce nmo-igg autoantibodies, leading to cases of lupus-derived nmo. the discovery of nmo-igg (anti-aqp4) has opened a new avenue of research into the causes. pathophysiology illustration of the four different types of glial cells found in the central nervous system: ependymal cells, astrocytes, microglial cells, and oligodendrocytes anti-aqp4+ variants main article: anti-aqp4 disease nmosd is usually caused by autoantibodies targeting aquaporin 4 (aqp4), a channel protein in the cell membrane that allows water to pass through the membrane. aqp4 monomers form tetramers, and the tetramers aggregate. aqp4 is found in astrocytes, which are the basis for the glymphatic system. thus, nmosd involving aqp4-igg can be considered an astrocytopathy or autoimmune astrocytic channelopathy, since the astrocytes are semi-selectively destroyed. the astrocytes surround the blood–brain barrier (bbb), a system responsible for preventing substances in the blood from entering the brain. for antibodies from the blood to reach astrocytes in the central nervous system (cns), they must cross the bbb, the mechanism of which is not completely known. some reports point to the metalloproteinase-2 and interleukin-6 as culprits responsible for the bbb failure. there is broad consensus that aqp4/nmo-igg initially enters the brain via bbb-deficient sites such as the area postrema, where there is access to cerebrospinal fluid (csp). in any case, anti-aqp4 is produced mainly intrathecally. within astrocytes, aqp4 is primarily found in astrocytic foot processes that abut blood vessels and the linings of the brain (meninges). nmosd brain lesions, as seen under a microscope, show igg, immunoglobulin m (igm), inflammatory cells, and complement deposits around blood vessels. aqp4-igg is a member of the igg1 immunoglobulin family, which is an activator of the complement system, which seems to play an integral part in the autoimmune response. there is a loss of astrocytes, and sometimes also a loss of neurons and oligodendrocytes. loss of cells other than astrocytes is a consequence of collateral inflammatory damage or astrocyte dysfunction. nmosd selectively affects the optic nerve, spinal cord, and brain stem. this selectivity can be explained by the increased amount of aqp4 in these structures, and, furthermore, by the increased amount of aqp4 aggregates in the optic nerve and spinal cord. the increased bbb permeability at the area postrema helps explain involvement there. aqp4 is present in tissues outside the central nervous system (e.g. the kidneys), but these tissues aren't affected in nmosd, at least in part because of the presence of autoimmune downregulators outside of the central nervous system. in nmosd, areas of brain tissue that appear normal in conventional magnetic resonance imaging (mri) can show damage in diffusion tensor imaging (dti), although less so compared to multiple sclerosis (ms). most research into the pathology of nmo has focused on the spinal cord. the damage can range from inflammatory demyelination to necrotic damage of the white and grey matters. the inflammatory lesions in nmo have been classified as type ii lesions (complement-mediated demyelination), but they differ from ms pattern ii lesions in their prominent perivascular distribution. therefore, the pattern of inflammation is often quite distinct from that seen in ms. aqp4-igg levels are coarsely correlated with nmosd disease activity, those levels generally increasing before relapse and declining during remission, with higher levels being correlated to more severe disease manifestation. nmo-igg-negative cases are less understood. it seems that astrocytes are spared in these cases. anti-mog+ variants main article: antimog associated encephalomyelitis the second most frequent autoantibody in nmo is mog-igg, which targets myelin oligodendrocyte glycoprotein (mog). mog is an integral membrane glycoprotein found on the surface of oligodendrocytes and the outermost surface of myelin sheaths. its function is not entirely known. mog-igg is produced outside the central nervous system (cns) despite mog existing only in the cns (with the bbb separating the two), leading to the hypothesis that mog drained via cerebral spinal fluid into lymph nodes causes autoimmune reaction formation. mog-igg-positive nmosd brain lesions, as seen under a microscopic, show demyelination with preservation of oligodendrocytes and axons, presence of inflammatory cells, and igg and complement deposits. mog-igg levels coarsely correlate with disease severity, with levels being higher during active disease, and higher levels being associated with more severe disease manifestation. antibodies against mog are considered mostly absent in similar diseases, such as ms. therefore, it can be said that anti-mog diseases are grouped within aqp4-igg-negative nmosd. together with anti-aqp4 disease, anti-mog diseases form the wider part of the nmo spectrum. the nmo cases are classified in four classes, according to the presence or absence of any of these two main auto-antibodies. the clinical course and the response to therapy is different for various diseases classed within these groups, showing a better prognosis for those in the nmo-ab(−)/mog-ab(−) group, and a worse prognosis for those in the nmo-ab(+)/mog-ab(+) group. the mog-related nmo can be radiologically identified by the conus involvement. myelin-oligodendrocyte glycoprotein antibody–positive patients were more likely to have conus involvement on spinal magnetic resonance imaging. diagnosis mri image of a patient with transverse myelitis, one of the diagnostic criteria for nmosd nmosd is diagnosed using consensus clinical criteria, which have undergone multiple revisions, most recently in 2015. diagnostic criteria are more relaxed for seropositive aqp4–igg cases than they are for seronegative aqp4-igg ones. if aqp4-igg is detected, then one core clinical criterion, along with the ruling out of alternative diagnoses, is sufficient for nmosd diagnosis. if aqp4-igg is undetected, or its status is unknown, two core clinical criteria, each with supportive mri findings, along with the ruling out of alternative diagnoses, are needed for an nmosd diagnosis. nmosd diagnostic criteria core criteriaadditional mri findings for absent/unknown aqp4-igg optic neuritiseither 1) brain mri showing normal findings or only nonspecific white matter lesions, or 2) optic nerve mri showing t2-hyperintesity, or t1 enhancing lesion, greater than 1/2 optic nerve length or involving optic chiasm acute myelitisintramedullary lesion > 3 contiguous segments, or spinal atrophy ≥ 3 contiguous segments area postrema syndrome (prolonged episodes of hiccuping or vomiting/nausea)dorsal medulla/area postrema lesions acute brainstem syndromeperiependymal brainstem lesions symptomatic narcolepsy/acute diencephalic clinical syndrome with an mri showing diencephalon lesion(s)none additional symptomatic cerebral syndrome with nmosd-typical brain lesion(s)none additional rarely, it has been reported that some courses of anti-nmdar are consistent with nmo. preliminary reports suggest that other autoantibodies may play a role in rare cases of nmo. nmosd with mog-igg is considered a manifestation of anti-mog associated encephalomyelitis. spectrum constituents after the development of the nmo-igg test, the spectrum of disorders comprising nmo was expanded. the spectrum is now believed to consist of: standard nmo, according to the diagnostic criteria described above limited forms of nmo, such as single or recurrent events of longitudinally extensive myelitis, and bilateral simultaneous or recurrent optic neuritis asian optic-spinal multiple sclerosis (osms), or aqp4+ osms. this variant can present brain lesions like ms does, but it should not be confused with an aqp4-negative form of inflammatory demyelinating diseases of the central nervous system spectrum, sometimes called optic-spinal ms longitudinally extensive myelitis or optic neuritis associated with systemic autoimmune disease optic neuritis or myelitis associated with lesions in specific brain areas such as the hypothalamus, periventricular nucleus, and brainstem nmo-igg negative nmo: aqp4 antibody-seronegative nmo poses a diagnostic challenge. some cases could be related to anti-myelin oligodendrocyte glycoprotein (mog) autoantibodies. differential diagnosis aqp4-ab-negative nmo presents problems for differential diagnosis. the behavior of the oligoclonal bands can help to establish a more accurate diagnosis. oligoclonal bands in nmo are rare and they tend to disappear after attacks, while in ms they are nearly always present and persistent. it is important to notice for differential diagnosis that, though uncommon, it is possible to have longitudinal lesions in ms. another problem for diagnosis is that aqp4-ab in mog-ab levels can be too low to be detected. some additional biomarkers have been proposed. nmo differs from ms in that it usually has more severe sequelae after an acute episode than standard ms, which infrequently presents as transverse myelitis. in addition oligoclonal bands in the csf as well as white matter lesions on brain mris are uncommon in nmo, but occur in over