Table 1.
Summary of clinical characteristics, investigations, and ‘red flags’ of diagnosis in all three patients
| Case 1 | Case 2 | Case 3 | Red flags | |
|---|---|---|---|---|
| Clinical characteristics | ||||
| Presenting phenotype | Sensory-left arm, tongue | Bilateral optic neuritis | Optic neuritis |
Initial presentation with bilateral optic neuritis and relapse with unilateral optic neuritis is highly suggestive of MOGAD Relapse with optic neuritis and transverse myelitis also favours MOGAD rather than MS ADEM phenotype is more common in childhood MOGAD |
| Relapse phenotype | Unilateral optic neuritis, myelitis, brainstem involvement | Unilateral optic neuritis, transverse myelitis | Bilateral optic neuritis, transverse myelitis | |
| Disease course | Relapsing | Relapsing | Relapsing | |
| Optic neuritis | Unilateral (relapse) | Bilateral (onset), unilateral (relapse) | Bilateral | |
| ADEM phenotype | Yes- on relapse | No | No | |
| Myelitis | Yes | Yes | Yes | |
| Brainstem involvement | Yes | No | No | |
| Cerebellar involvement | No | No | No | |
| Response to steroids | Recovery from relapse | Recovery from relapse | Recovery from relapse | |
| Associated autoimmune diseases | Yes | No | No | |
| MRI brain | ||||
| Supratentorial lesions at onset | Yes | Yes | Yes |
Dawson’s fingers, U-fibre lesions, and periventricular lesions favour MS ADEM-type lesions favour MOGAD. Optic nerve involvement is pre-chiasmatic and longitudinally extensive in MOGAD. Perineural and periorbital enhancement favours MOGAD. 15% of MOGAD fulfill McDonald criteria for MS |
| ADEM-like lesions (bilateral, asymmetrical) | Yes (during relapse) | No | No | |
| Brainstem lesions | Yes | No | No | |
| Dawson’s fingers | No | Yes | Yes | |
| Subcortical U-fibre lesions | No | No | No | |
| ≥ 1 lesion adjacent to lateral ventricle | Yes | Yes | Yes | |
| MRI spine | ||||
| Length of lesions | Short segment, multiple | Short segment, multiple | Longitudinally extensive, multiple | Longitudinally extensive central lesions with grey matter involvement favour MOGAD |
| Location of lesions | Cervical, thoracic | Cervical, thoracic | Cervical, thoracic | |
| Contrast enhancement | No | No | No | |
| CSF | ||||
| Pleocytosis | Nil | Not available | Lymphocytes 2X106/L | In MOGAD, pleocytosis is variable & intrathecal OCB occur in 5–20% of patients. In MS, OCB present in 95%. Pleocytosis usually absent in MS |
| Protein | Normal | Not available | 0.66 g/L (normal 0.15–0.45 g/L) | |
| Oligoclonal bands (OCB) | Negative | Not available | Positive | |