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Multiple sclerosis-like NMOSD patients suffer severe worsening of status after fingolimod initiation
Mickael Bonnan1, Emeline Berthelot2, Philippe Cabre2
1Service de Neurologie, Centre Hospitalier de Pau, 4 Bd Hauterive, 64000 Pau, France.
Background:
Initial clinical manifestations of NMOSD may rarely overlap with MS. Fingolimod may trigger severe attacks in patients with NMOSD previously misdiagnosed as MS. These cases are rare and their pathophysiology remains elusive.
Methods:
We recruited all NMOSD patients treated by fingolimod in a single-center cohort of Afro-Caribbean neuro-inflammatory patients in Fort-de-France (French West Indies). Six patients were collected from the literature.
Results:
Among 622 patients followed locally for MS, 101 received fingolimod and two suffered severe attacks revealing a typical NMOSD presentation. These two patients were found to have AQP4-IgG. The risk of misdiagnosed NMOSD in MS in our high-risk Afro-Caribbean patients was estimated to be 1.9% (0 to 4.7%). Among the whole cohort, relapses occurred within a month after fingolimod initiation in five patients. All attacks were severe and contrasted with previously benign attacks, suggesting a shift to a more severe disorder. An unusual finding in these patients was large brain lesions.
Conclusion:
AQP4-IgG should be obtained before initiation of fingolimod in high-risk patients, especially in those from areas of high NMOSD prevalence.
Insights
Fingolimod can trigger severe attacks in patients with neuromyelitis optica spectrum disorder (NMOSD) misdiagnosed as multiple sclerosis (MS). Testing for AQP4-IgG antibodies before fingolimod treatment is crucial for high-risk individuals.
Area of Science:
- Neuroimmunology
- Clinical Neurology
Background:
- Neuromyelitis optica spectrum disorder (NMOSD) and multiple sclerosis (MS) can present with overlapping initial symptoms.
- Fingolimod, a treatment for MS, may precipitate severe attacks in NMOSD patients misdiagnosed with MS.
Purpose of the Study:
- To investigate the risk of severe attacks in NMOSD patients treated with fingolimod.
- To assess the prevalence of misdiagnosed NMOSD among MS patients in a high-risk population.
Main Methods:
- Retrospective analysis of NMOSD patients treated with fingolimod in a single-center cohort.
- Inclusion of six NMOSD patients from existing literature.
- Estimation of misdiagnosed NMOSD risk in a high-risk Afro-Caribbean MS cohort.
Main Results:
- Two out of 101 MS patients treated with fingolimod experienced severe attacks indicative of NMOSD, both testing positive for AQP4-IgG.
- The estimated risk of misdiagnosed NMOSD in this high-risk cohort was 1.9%.
- Five patients experienced relapses within a month of fingolimod initiation, characterized by severe attacks and large brain lesions.
Conclusions:
- Testing for AQP4-IgG antibodies is recommended before initiating fingolimod in patients at high risk for NMOSD.
- Particular caution is advised for patients from regions with high NMOSD prevalence.
