Limb Weakness and Vision Loss in a 30-Year-Old Man

Sumaira Nabi, MBBS; Shahzad Ahmed, MBBS; Muhammad Tariq, MBBS, FRCP

Disclosures

November 10, 2015

The initial treatment for acute attacks of optic neuritis or myelitis is mainly high-dose intravenous corticosteroid therapy.[20] Plasmapheresis (1-1.5 L plasma volume per exchange) over a 2-week period may be initiated in patients who do not respond to treatment with corticosteroids.[21] Interferon and natalizumab are not effective for prevention of NMO relapses and may even lead to worsening of symptoms.[22,23,24] Azathioprine, with or without prednisolone, and rituximab are considered the first-line therapies.[25] Monthly pulse cyclophosphamide, mitoxantrone, mycophenolate mofetil, and methotrexate have been suggested as second-line therapies.

Cyclosporin A has been used in a small case series for patients with NMO.[26] Evidence for the use of intermittent plasma exchange and intravenous Ig for relapse prevention is insufficient.[25] Other, newer agents under study that have shown promise include eculizumab, a humanized monoclonal antibody against the complement protein C5, and tocilizumab, a humanized anti-interleukin-6 antibody.[27,28] The role of anti-aquaporin-4 monoclonal antibody blocker is also being investigated.[29]

This case highlights the fact that with lack of serologic assays, such as detection of NMO IgG antibodies in resource-limited settings, clinicians must rely on clinical judgment, neuroimaging, and other supportive lab tests and must promptly initiate treatment so as to delay and decrease the morbidity and mortality associated with NMO.

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