Skip to content


  • Review
  • Open Access

Antibodies in acquired demyelinating disorders in children

  • 1, 2Email author,
  • 1, 3,
  • 1, 4,
  • 1, 4 and
  • 1, 4
Multiple Sclerosis and Demyelinating Disorders20161:5

  • Received: 20 November 2015
  • Accepted: 1 April 2016
  • Published:


The discovery that several demyelinating disorders in children may be associated with autoantibodies to astrocytes, myelin, and/or synaptic proteins has opened the possibility of their use as diagnostic and prognostic biomarkers. The identification of aquaporin 4 (AQP4) antibodies as specific diagnostic markers of neuromyelitis optica (NMO) led to an expansion of the clinical spectrum of this disorder to include patients with incomplete forms or with manifestations outside of the optic nerves and spinal cord. Recently, an international panel of experts proposed the use of the term NMO spectrum disorders (NMOSD) to encompass all of these phenotypes. Although rare in children, the early identification of AQP4 antibodies has important prognostic and therapeutic implications as their presence is highly predictive of relapses and accumulation of disability. More recently, antibodies to myelin oligodendrocyte glycoprotein (MOG) have been described in children and adults diagnosed with NMOSD and seronegative for AQP4 antibodies, as well as in children with other acquired demyelinating disorders. For example 60 % of children with acute demyelinating encephalomyelitis (ADEM) have MOG antibodies. Whether MOG antibodies are pathogenic or surrogate biomarkers of the disease is unclear but their identification is important for two reasons. First, patients with a first demyelinating event who are MOG antibody positive are unlikely to develop multiple sclerosis (MS); and second, the long-term persistence of MOG antibodies associates with recurrent non-MS demyelinating disorders such as NMOSD, recurrent optic neuritis or transverse myelitis, or multiphasic ADEM. Other antibodies, such as those targeting Kir 4.1 or the glycine receptor have also been described in association with pediatric MS and other demyelinating disorders but their clinical relevance, and existence, in the case of Kir 4.1, is still under investigation. The focus of this review will be the current data on the antibodies mentioned above, and the recent discovery that some children have both a demyelinating disorder and autoimmune encephalitis. The presence of antibodies against targets related to demyelinating disorders (AQP4 or MOG) and those related to autoimmune encephalitis (e.g., N-methyl-D-aspartate receptor), supports the concurrence of two autoimmune disorders in these patients.


  • AQP4
  • Antibodies
  • MOG
  • ADEM
  • White matter
  • Overlap
  • Encephalitis
  • Children


To establish the correct diagnosis and prognosis after a first demyelinating episode in a child is challenging as, at this age, different acquired demyelinating disorders (ADS) can present with similar clinical features. It can be difficult to distinguish between a monophasic illness such as acute demyelinating encephalomyelitis (ADEM), which will not require long-term treatment, and the first episode of a chronic or relapsing disorder such as multiple sclerosis (MS), neuromyelitis optica spectrum disorders (NMOSD), or multiphasic ADEM, in which early initiation of treatment can be crucial for preventing long-term disability [1]. Brain and spinal cord MRI as well as the evaluation for the presence of oligoclonal bands in the cerebrospinal fluid (CSF), are well-characterized tools that can assist in formulating the diagnosis of ADS [2, 3]. More recently, the discovery that several ADS may be associated with autoantibodies to astrocytes, myelin, and/or synaptic proteins opens the possibility of utilizing these as biomarkers for diagnosis, prognosis and choice of appropriate therapies [46]. Here we review the current knowledge about the antibodies associated with ADS in children. The demographic, clinical and laboratory information according to the antibody is summarized in Table 1.
Table 1

Antibodies in acquired demyelinating disorders in children


AQP4 antibodies

MOG antibodies

Kir 4.1 antibodies

NMDAR antibodies

Glycine R antibodies


NMOSD with predominant involvement of optic nerve and spinal cord. Additional manifestations are related to involvement of other areas rich in AQP4, such as area postrema (hiccups or nausea and vomiting), hypothalamus, surrounding the third ventricle (symptomatic narcolepsy or acute diencephalic syndrome), brainstem/cerebral syndrome. Non-CNS involvement: musculoskeletal and hyperCK

Described in all types of ADS; predominant in ADEM, followed by in order of frequency in NMOSD, optic neuritis, and extensive myelitis. Rarely seen and at lower titers in multiple sclerosis

Described in association with adults (47%) and children (57%) with multiple sclerosis; results have not been reproduced by other investigators who showed much lower association (< 1–24%) and positive results in controls including NMOSD patients

Anti-NMDAR encephalitis: psychiatric symptoms, seizures, amnesia, movement disorders, catatonia, autonomic instability, and coma.

Stiff person syndrome in isolation or with concurrent glutamic acid decarboxylase antibodies, progressive encephalomyelitis with rigidity and myoclonus, and rarely in several types of demyelinating syndromes: optic neuritis, multiple sclerosis

Rarely, overlap with clinical and/or radiological ADS, frequently with concomitant MOG and/or AQP4 antibodies: presentation can be sequential or simultaneous


Activate complement and disrupt the AQP4 water channel located at astrocyte end-feet

Whether MOG antibodies are pathogenic or serve as surrogate biomarkers of the disease is currently unclear

Clinical significance and existence remains a matter of debate

In vitro and in vivo models show decrease levels of NMDAR

Lack of clinical syndrome specificity and the fact these antibodies are frequently found in patients with ADS concurrent with other more pathogenically relevant antibodies such as MOG and/or AQP4, suggests nonspecific immune activation

Age, Sex

More common in adults (median age 39 years), but the disorder affects patients of all ages with a female predominance

Mostly in children with no sex predominance

No differences were found compared to MS patients without these antibodies

Predominant in children and young adults. Sex and tumor association (teratoma) is agedependent, but no tumor association has been described in patients with overlapping ADS

Predominance depends on the syndrome in which the antibodies are analyzed; in ADS, there are no differences compared to patients without these antibodies.


Spinal cord lesions extending over ≥ 3 contiguous segments (Fig. 1a, d); area postrema lesions; periependymal brainstem lesions; chiasmatic involvement; and diencephalic lesions. In children, extensive brain lesions similar to that found in ADEM

Typically large, hazy, bilateral lesions in patients with ADEM and MOG antibodies (Fig. 1b, c). Patients with NMOSD can show similar MRI features to those found in patients with AQP4 antibodies

No specific reported data comparing MRI features of patients with or without these antibodies

Normal or T2/FLAIR nonspecific findings in anti-NMDAR encephalitis but can show demyelinating features with overlapping ADS

Depends on the associated clinical syndrome; in ADS very few reported patients but appears to be no differences compared to patients without these antibodies


The presence of AQP4 antibodies in NMOSD patients is associated with increased risk of recurrences and increased long-term disability compared to patients without these antibodies. AQP4 antibody titers persist long term.

Frequently monophasic course with good recovery (antibody titers often become negative) (Fig. 1e, f). In some cases, associated with non-MS multiphasic disease; there can be long-term persistence of antibodies. NMOSD patients with MOG antibodies have better prognosis compared to patients with AQP4 antibodies

No differences were found compared to MS patients without these antibodies. One study found higher titers during relapse versus remission in patients with MS

15–25% of patients of anti-NMDAR encephalitis may develop recurrences. Prevalence of NMDAR encephalitis or ADS relapses is unknown in overlapping syndromes

Depends on the associated clinical syndrome; in ADS very few reported patients but appears to be no differences compared to patients without these antibodies

Laboratory Test

Serum CBA (microscopy or flow cytometry-based detection) had a sensitivity of 76.7% in a pooled analysis and 0.1% falsepositive rate in a multiple sclerosis clinic cohort. Indirect immunofluorescence assays and ELISAs have lower sensitivity (63–64% each) and occasionally yield false-positive results (0.5–1.3% for ELISA), especially when the titer is low

Serum CBA (positivity threshold is considered up to 1/160). Some authors use human IgG1 subclass as a secondary antibody to avoid false positive results. ELISA was used in the past with controversial results, and this technique is not recommended


Fixed CBA and immunochemistry. Lower sensitivity in serum compared with CSF (85 vs 100%), and false positive results are possible when only serum is tested. Confirmation by two different techniques is preferred when the clinical syndrome does not fit with the lab result or when only serum is tested

Live CBA (positivity threshold is considered up to 1/80)

ADEM acute demyelinating encephalomyelitis; ADS acquired demyelinating disorders; AQP4 aquaporin 4; CBA cell-based assay; CSF cerebrospinal fluid; FLAIR fluid-attenuated inversion recovery; Glycine R glycine receptor; MOG myelin oligodendrocyte glycoprotein; NMDAR N-methyl-d-aspartate receptor; NMOSD neuromyelitis optica spectrum disorders

Fig. 1
Fig. 1

MRI in children with demyelinating syndromes associated with MOG or AQP4 antibodies. (a, d): Brain and spinal cord MRI of a 13-year old girl with NMOSD and AQP4 antibodies. The sagittal MRI of the spinal cord shows hyperintensity involving more than 3 segments (a) whereas the brain axial T2-sequence shown in (d) is normal. (b, c, e, f): Coronal FLAIR-sequences of an 8-year old girl with an initial episode of ADEM and MOG antibodies showing bilateral widespread subcortical lesions (b, c). Seven months after the attack there has been complete resolution of the lesions (e, f)

Antibodies to astrocytes or myelin proteins

Anti-Aquaporin 4 (AQP4) antibodies and NMOSD

Neuromyelitis optica (NMO) is a rare disease. Population-based studies estimate a prevalence of 0.52–4.4 cases/100,000 inhabitants, with differences across studies according to geographic and ethnic cohorts [7]. NMO is characterized by recurrent inflammatory episodes that preferentially affect the optic nerves and spinal cord [8]. The disorder predominantly affects women (90 %), and although the median age at onset is 39 years, patients of all ages can be affected including children and the elderly [9]. Overall, up to 90 % of patients have a recurrent form of the disease, frequently with incomplete recovery between relapses with incremental disability [10, 11]. Although NMO was initially considered to be an optical-spinal form of MS, today it is accepted as a distinct clinical-pathological entity. The underlying pathophysiology was suspected to be B-cell mediated due to distinctive pathologic findings showing vasculocentric deposition of immunoglobulins (Ig), complement components within lesions, and predominance of neutrophils and eosinophils in the inflammatory infiltrates that are typical features of a type-2 T-helper cell immune response [12]. The involvement of the humoral immune system in NMO was confirmed by Lennon and colleagues with the identification of antibodies against AQP4, a water channel expressed predominantly in astrocyte end-feet [4, 13]. Subsequent studies demonstrated that AQP4 antibodies, which belong to the IgG1 subclass, activate complement and disrupt the AQP4 water channel, disturbing water homeostasis, promoting edema and perivascular inflammation [14, 15]. The pathogenic role of AQP4 antibodies in NMO has been demonstrated in murine models showing NMO-like lesions after passive transfer of AQP4 antibodies from human patients [15, 16].

The identification of AQP4 antibodies led in 2006 to revised NMO criteria [8]. In 2007 the term NMOSD was introduced to include AQP4 seropositive patients with limited or inaugural forms (e.g., recurrent optic neuritis or longitudinally extensive transverse myelitis [LETM]), and those with manifestations outside of the optic nerves and spinal cord (e.g., intractable hiccups or vomiting), secondary to involvement of areas also known to be rich in AQP4 such as periventricular areas of the third and fourth ventricles, and periaqueductal and parahippocampus grey matter [1719]. Most recently, an International Panel proposed new diagnostic criteria that unified under the term NMOSD traditional NMO and modern NMOSD definitions [20]. The main reasons for the unifying term were based on the assumption that there are no biological differences between patients diagnosed with NMO and those with NMOSD in AQP4 seropositive patients, and that patients with limited forms frequently develop subsequent clinical attacks consistent with conventional NMO in AQP4 seropositive patients [20]. For example, in a comparative study of patients with AQP4 antibodies and NMO and patients with limited forms, we found no differences in motor or visual disability outcome, supporting the use of the term NMOSD for patients with AQP4 antibodies [21]. However, the 2015 criteria allow the diagnosis of NMOSD in patients without AQP4, incorporating these patients into the same group as those with AQP4, and this is controversial. For example, there are studies that have shown some clinical differences between AQP4 positive and negative patients including a lower female predominance in those without AQP4-IgG [22, 23]. The phenotypic variability between AQP4 positive and negative patients may be partially explained by the presence of antibodies to myelin oligodendrocyte glycoprotein (MOG) in a subgroup of AQP4 seronegative patients, as patients with MOG antibodies may develop a clinical picture indistinguishable from NMOSD but with better outcome [22, 24]. This likely represents a different immunopathogenic mechanism that would not be clear using descriptive clinical terms, such as NMO or NMOSD [24]. Therefore, some authors suggest replacing these terms by a pathogenically descriptive name such as “autoimmune channelopathy due to AQP4 antibodies” to exclude patients without AQP4 antibodies such as patients with MOG antibodies, which probably underly a different biologic disease. Autoimmune channelopathy due to AQP4 antibodies would also encompass other AQP4 related non-CNS disorders such as the recently described disorders with hyperCKemia and/or skeletal muscle involvement [25, 26]. This systemic involvement is not surprising as AQP4 channels are also expressed in normal muscles [27].

Characteristics of NMOSD with AQP4 antibodies in children

It is estimated that almost 70 % of adults with NMOSD have AQP4 antibodies [28]. In contrast these antibodies are rare in the pediatric population [29]. Among different prospective case series, up to 5 % of children with demyelinating diseases harbor these antibodies [30, 31]. However, a study evaluating specific clinical phenotypes found that almost half of children with classic NMO features harbored AQP4 antibodies [30].

The presence of these antibodies has important clinical and prognostic implications. For example, seropositivity for AQP4 antibodies in a first inflammatory episode is highly predictive for relapses, and relapses are associated with long-term disability in both children and adults [9, 29, 30]. In a series of 48 children with NMOSD and AQP4 antibodies, 54 % had visual impairment (27 % bilateral visual acuity ≤ 20/200), 54 % had residual weakness (29 % with paraparesis), and 12 % had sphincter involvement at last follow-up (median 12 months) [29].

Another example of the importance of identifying these antibodies is that in children AQP4 antibody associated disorders can present with encephalopathy mimicking ADEM or with lesions on brain MRI that simulate MS [1, 29, 32, 33]. Moreover, CSF abnormalities in pediatric MS may mimic those ordinarily considered suggestive of NMOSD [29, 30, 33]. Additionally, while an adult with LETM is commonly suspected to have AQP4-NMOSD, in children, this diagnosis is often not suspected as LETM also occurs with ADEM and MS [1]. Other differences between children and adults with NMOSD appears to be a lower female preponderance in children (3:1 female:male ratio compared with up to 9:1 for adults) [33]; and that a greater proportion of children may have monophasic disease [30, 33]. Aside from these caveats, the currently proposed diagnostic criteria for NMOSD are considered appropriate for pediatric patients [20].

Misdiagnosing NMOSD for MS in children can be deleterious as standard treatments for MS such as beta interferon, fingolimod or natalizumab can result in worsening of NMOSD [34, 35]. In contrast, treatment strategies that selectively target the cellular and soluble components of the humoral immune response in NMOSD, such as plasma exchange and B-cell depletion (e.g., rituximab), have been shown to be effective in the prevention of NMOSD relapses [36].

Based in the growing knowledge about the pathophysiology of NMOSD with AQP4 antibodies there are many studies examining new targeted therapies that will hopefully result in better outcomes for these patients. Examples include eculizumab, which acts to inhibit complement activation; tocilizumab, which acts by blocking the cytokine IL6 receptor; antibodies directed against the CD19 molecule expressed by B cells; and the monoclonal antibody aquaporimab, which is designed to block the interaction between human IgG and AQP4 [3740].

In summary, for the reasons noted above although the prevalence of AQP4 antibodies is low in the pediatric population, determination of these antibodies should be considered in any child with a first demyelinating episode involving one or more areas rich in AQP4.

MOG antibody-associated disorders in children

Antibodies against MOG have been associated with several types of acquired demyelinating disorders in children [5]. The specificity of MOG antibodies for demyelinating disorders was questioned in the past due to conflicting results from studies using ELISA or western blot, techniques that measure antibody binding to linear epitopes. More recently, the use of CBA (cell-based assays), in which antibody binding to conformational epitopes is assessed, has shown that MOG antibodies are able to identify patients with acquired demyelinating disorders [5]. These findings demonstrate the value of a multi-technique laboratory approach in autoantibody research and validation. Although there is some in vitro and in vivo data suggesting a pathogenic role of MOG antibodies, [41] there are no studies demonstrating that passive transfer of these antibodies leads to clinical disease, as has been demonstrated in animal models of AQP4 autoimmunity [16].

Whether MOG antibodies are pathogenic or represent surrogate biomarkers of the disease is currently unclear. However, preliminary data support that the determination of these antibodies is important [5]. In children, ADEM is the clinical syndrome that most frequently associates with MOG antibodies (present in up to 60 % of cases) [5]. A recent study compared 19 children with ADEM with MOG antibodies to 14 patients with ADEM without these antibodies [42]. There were no differences in in age at presentation, gender, symptoms, initial disease severity, or the presence of oligoclonal bands between children with or without MOG antibodies. However, children with ADEM and MOG antibodies more often had MRI findings characterized by large, hazy, bilateral lesions in the brain and an increased frequency of LETM. Children with MOG also had more favorable outcomes compared to those lacking these antibodies [42].

Several studies have shown that MOG antibody titers decline and become negative over time in patients with monophasic ADEM [43, 44]. A few initial reports postulated that the long-term persistence of MOG antibodies in a child could be predictive of the eventual development of pediatric MS [43]. Recent studies demonstrate that in fact, MOG antibodies are rarely found in pediatric MS and their presence supports a diagnosis other than MS [45]. For example, in a recent prospective series of 65 children with a first demyelinating attack, only 2/23 (9 %) with MOG antibodies compared with 16/42 (38 %) without these antibodies were diagnosed with MS after one year of follow-up, supporting the positive predictive value of MOG antibodies for a non-MS disease course [45]. However as these studies are based on short follow-up periods, longer time is needed to exclude eventual conversion to MS.

In contrast, there are several studies in children that support an association of the long-term persistence of MOG antibodies with recurrent non-MS demyelinating disorders such as NMOSD, recurrent optic neuritis, transverse myelitis or multi-phasic ADEM (Armangue personal observation) [41, 4648]. Interestingly, these antibodies have also been described in a subgroup of ADS patients who initially presented with monophasic ADEM that fulfilled all clinical and neuroradiological criteria who subsequently develop one or more episodes of optic neuritis (ON) without further neuroradiological changes suggestive of demyelination. This clinical scenario named by some authors as ADEM-ON, [49] does not fall into any of the current diagnostic categories of ADS in children proposed by the International Pediatric MS Study Group, [1] but these patients who are at risk for subsequent clinical events could have NMOSD, chronic relapsing inflammatory optic neuropathy or MS, require close follow-up.

After ADEM, the most frequent syndrome associated with MOG antibodies in children is NMOSD (20 % of patients) [5, 50]. Compared to NMOSD with or without AQP4 antibodies, NMOSD with MOG antibodies has distinctive clinical and prognostic features [22, 51, 52]. Patients with NMOSD and MOG antibodies are slightly more likely to be male in contrast to the greater female predominance in cases associated with AQP4. Patients with NMOSD with MOG are more likely to have optic nerve than spinal cord involvement as well as more frequent involvement of the conus and the basal ganglia on MRI, in contrast to what is seen in NMOSD AQP4 patients [22, 51, 52].

In adults, the presence of MOG is predictive of better outcome in NMOSD compared to NMOSD with AQP4 antibodie [22, 51, 52]. In a study in which we evaluated 174 adults patients with NMOSD, ON or transverse myelitis, patients with MOG antibodies more frequently had a monophasic course (41 % vs 7 %) and better prognosis (median EDSS score 1.5 vs 4.0) compared to patients with AQP4 antibodies, despite having similar severity scores at disease onset [22]. Whether these results can be extrapolated to the pediatric population is unknown and requires further study.

Pathological studies are not available from patients with NMOSD and MOG antibodies. Studies of CSF from these patients show increased levels of myelin basic protein and undetectable levels of glial fibrillary acidic protein (GFAP). This is in contrast to the CSF findings in patients with NMOSD and AQP4 antibodies that show low levels of myelin basic protein and elevated GFAP [53]. This supports the hypothesis that MOG associated disease is due to demyelinating pathology rather than an astrocytopathy, and this could explain the clinical differences between NMOSD patients with AQP4 and those with MOG antibodies.

Kir 4.1 IgG antibodies

In 2012, the KIR4.1 (also known as KCNJ10), a glial inwardly rectifying potassium channel expressed on oligodendrocytes and astrocytes, was proposed as a putative MS autoantigen. Using ELISA, the investigators reported KIR4.1-channel-specific IgG in serum of 47 % (189/397) of adult MS patients and < 1 % of patients with other neurological disorders [54]. In a subsequent study these antibodies were also reported in the serum of 57 % (24/47) of children with acquired demyelinating syndromes [55]. However this high prevalence of anti-KIR4.1 antibodies in patients with MS has not been corroborated by other groups. Using similar methods, other studies in MS patients have shown much lower frequencies of these antibodies (from < 1 to 26 %), and the antibodies were also present to the same degree in normal subjects and other disease controls such as NMOSD patients [5658]. Moreover, a recent study using a multi-technique approach did not detect KIR4.1-specific IgG in serum or CSF from patients with MS. No KIR4.1 loss from glia was seen in MS lesions and false positive results were demonstrated on ELISA [56]. The discrepancies between the results of these studies are difficult to explain, [59] but different analytical approaches might, in part, explain the contradictory findings. The potential relationship between KIR4.1 antibodies in MS deserves further investigation [59].

Antibodies to the Neuronal Cell Surface

Overlap between demyelinating syndromes and autoimmune encephalitis

The differential diagnosis of encephalopathy in children includes ADEM, NMOSD and autoimmune encephalitis associated with antibodies to neuronal cell-surface or synaptic proteins such as N-methyl-D-aspartate receptor (NMDAR) and others [60]. The clinical syndrome of anti-NMDAR encephalitis is highly predictable in adults and teenagers and is characterized by the onset of psychiatric and behavioral problems that progress to decreased level of consciousness, seizures, dyskinesias, choreathetoid movements or postures, and breathing or autonomic instability [61, 62]. In young children, the syndrome is similar, but children more frequently present with seizures or abnormal movements. Moreover, behavioral changes are often misdiagnosed as they may include new onset temper tantrums or agitation, which are frequent and non-specific at this age [62, 63]. In contrast to what is found in ADEM or in other ADS, in anti-NMDAR encephalitis brain MRI is typically normal or may show non-specific FLAIR/T2 changes, sometimes with transient cortical-meningeal enhancement [64]. A new challenge that has emerged is the finding that patients may have both demyelinating disease and autoimmune encephalitis [6]. The presence of two immune disorders in these patients is supported by the finding of antibodies against targets related to demyelinating disorders (AQP4 or MOG) and those related to autoimmune encephalitis (e.g., NMDAR) [6]. In these patients, the two disorders may occur sequentially as independent episodes separated by weeks to years or may occur simultaneously [6, 65]. The latter is the most diagnostically challenging. The presence of clinical or radiologic features characteristic of demyelination in a patient with autoimmune encephalitis and neuronal cell-surface antibodies should prompt testing for MOG and/or AQP4 antibodies. Similarly, patients with demyelinating disorders who develop unusual symptoms such as dyskinesias, refractory seizures, or prominent psychiatric symptoms should be tested for cell-surface antibodies (preferably in CSF, see Table 1) [6, 66]. While the identification of different antibodies can confirm the dual diagnoses, awareness that these disorders may overlap is the first step to establishing the correct diagnoses.

Glycine antibodies and demyelinating syndromes

Antibodies to glycine receptor (GlyR) were initially detected in serum and CSF of patients with progressive encephalomyelitis with rigidity and myoclonus (PERM), [67] but have since been reported in other subgroups of patients including patients with stiff-person syndrome, cerebellar ataxia and several types of demyelinating disorders in children and adults (e.g., optic neuritis and MS) [31, 68, 69].

This lack of syndrome specificity and the fact these antibodies are frequently found in patients with ADS concurrent with other more pathogenically relevant antibodies such as MOG and/or AQP4, [69] suggests that these antibodies may be non-specific markers of autoimmunity.


The differential diagnoses of a child presenting with a first episode of demyelination is wide and includes diseases with different pathogenic mechanisms. This can delay diagnosis and initiation of appropriate therapies, which may affect disease course and outcome.

The discovery of AQP4 antibodies allows for early identification of patients with similar pathophysiology and prognosis, thereby supporting the use of specifically directed therapeutic interventions. Antibodies to MOG have recently been postulated to be markers of non-MS demyelinating diseases in children and may identify patients with high risk of developing relapses. The identification of AQP4 or MOG antibodies concurrent with NMDAR antibodies in patients with autoimmune encephalitis has uncovered the fact that some patients can have both autoimmune encephalitis and a demyelinating disorder. Further investigation will clarify the role of the antibodies discussed above in these diseases and will likely lead to the discovery of additional antibody biomarkers that may facilitate diagnosis and serve as prognostic tools.



acute demyelinating encephalomyelitis




cerebrospinal fluid


glial fibrillary acidic protein


glycine receptor




longitudinally extensive transverse myelitis


myelin oligodendrocyte glycoprotein


multiple sclerosis




neuromyelitis optica


neuromyelitis optica spectrum disorders


optic neuritis


progressive encephalomyelitis with rigidity and myoclonus



We thank Myrna Rosenfeld for critical review of the manuscript and all participating physicians and patients for their generous contribution to this research. This work was supported in part by Instituto Carlos III, Madrid, Spain (CM14/00081 TA); Dodot Procter & Gamble research grant sponsored by Asociación Española de Pediatría (AEP) (DN040579, TA); and Fundació Marató TV3 (20141830, TA, MS, FG, AS).

Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (, which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( applies to the data made available in this article, unless otherwise stated.

Authors’ Affiliations

Neuroimmunology Program, Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Hospital Clínic, University of Barcelona, c/ Casanova 143 CELLEX 3A, 08036 Barcelona, Spain
Pediatric Neuroimmunology Unit, Neurology Department, Sant Joan de Déu Childrens Hospital, Esplugues del Llobregat, University of Barcelona, Barcelona, Spain
Division of Pediatric Neurology, The Johns Hopkins University School of Medicine, Baltimore, USA
Neurology Department, Hospital Clínic, University of Barcelona, Barcelona, Spain


  1. Krupp LB, Tardieu M, Amato MP, et al. International Pediatric Multiple Sclerosis Study Group criteria for pediatric multiple sclerosis and immune-mediated central nervous system demyelinating disorders: revisions to the 2007 definitions. Mult Scler. 2013;19:1261–7.View ArticlePubMedGoogle Scholar
  2. Polman CH, Reingold SC, Banwell B, et al. Diagnostic criteria for multiple sclerosis: 2010 revisions to the McDonald criteria. Ann Neurol. 2011;69:292–302.View ArticlePubMedPubMed CentralGoogle Scholar
  3. Heussinger N, Kontopantelis E, Gburek-Augustat J, et al. Oligoclonal bands predict multiple sclerosis in children with optic neuritis. Ann Neurol. 2015;77:1076–82.View ArticlePubMedGoogle Scholar
  4. Lennon PVA, Wingerchuk DM, Kryzer TJ, et al. A serum autoantibody marker of neuromyelitis optica: Distinction from multiple sclerosis. Lancet. 2004;364:2106–12.View ArticlePubMedGoogle Scholar
  5. Reindl M, Di Pauli F, Rostásy K, Berger T. The spectrum of MOG autoantibody-associated demyelinating diseases. Nat Rev Neurol. 2013;9:455–61.View ArticlePubMedGoogle Scholar
  6. Titulaer MJ, Höftberger R, Iizuka T, et al. Overlapping demyelinating syndromes and anti-N-methyl-D-aspartate receptor encephalitis. AnnNeurol. 2014;75:411–28.Google Scholar
  7. Pandit L, Asgari N, Apiwattanakul M, et al. Demographic and clinical features of neuromyelitis optica: A review. Mult Scler. 2015;21:845–53.View ArticlePubMedPubMed CentralGoogle Scholar
  8. Wingerchuk DM, Lennon VA, Pittock SJ, Lucchinetti CF, Weinshenker BG. Revised diagnostic criteria for neuromyelitis optica. Neurology. 2006;66:1485–9.View ArticlePubMedGoogle Scholar
  9. Tillema JM, McKeon A. The spectrum of neuromyelitis optica (NMO) in childhood. J Child Neurol. 2012;27:1437–47.View ArticlePubMedGoogle Scholar
  10. Matiello M, Lennon VA, Jacob A, et al. NMO-IgG predicts the outcome of recurrent optic neuritis. Neurology. 2008;70:2197–200.View ArticlePubMedGoogle Scholar
  11. Weinshenker BG, Wingerchuk DM, Vukusic S, et al. Neuromyelitis optica IgG predicts relapse after longitudinally extensive transverse myelitis. Ann Neurol. 2006;59:566–9.View ArticlePubMedGoogle Scholar
  12. Lucchinetti CF, Mandler RN, McGavern D, et al. A role for humoral mechanisms in the pathogenesis of Devic’s neuromyelitis optica. Brain. 2002;125:1450–61.View ArticlePubMedGoogle Scholar
  13. Lennon VA, Kryzer TJ, Pittock SJ, Verkman AS, Hinson SR. IgG marker of optic-spinal multiple sclerosis binds to the aquaporin-4 water channel. J Exp Med. 2005;202:473–7.View ArticlePubMedPubMed CentralGoogle Scholar
  14. Saadoun S, Waters P, Bell BA, Vincent A, Verkman AS, Papadopoulos MC. Intra-cerebral injection of neuromyelitis optica immunoglobulin G and human complement produces neuromyelitis optica lesions in mice. Brain. 2010;133:349–61.View ArticlePubMedPubMed CentralGoogle Scholar
  15. Jarius S, Wildemann B. AQP4 antibodies in neuromyelitis optica: diagnostic and pathogenetic relevance. Nat Rev Neurol. 2010;6:383–92.View ArticlePubMedGoogle Scholar
  16. Bradl M, Misu T, Takahashi T, et al. Neuromyelitis optica: Pathogenicity of patient immunoglobulin in vivo. Ann Neurol. 2009;66:630–43.View ArticlePubMedGoogle Scholar
  17. Wingerchuk DM, Lennon VA, Lucchinetti CF, Pittock SJ, Weinshenker BG. The spectrum of neuromyelitis optica. Lancet Neurol. 2007;6:805–15.View ArticlePubMedGoogle Scholar
  18. Misu T, Fujihara K, Nakashima I, Sato S, Itoyama Y. Intractable hiccup and nausea with periaqueductal lesions in neuromyelitis optica. Neurology. 2005;65:1479–82.View ArticlePubMedGoogle Scholar
  19. Iorio R, Lucchinetti CF, Lennon VA, et al. Syndrome of inappropriate antidiuresis may herald or accompany neuromyelitis optica. Neurology. 2011;77:1644–6.View ArticlePubMedPubMed CentralGoogle Scholar
  20. Wingerchuk DM, Banwell B, Bennett JL, et al. International consensus diagnostic criteria for neuromyelitis optica spectrum disorders. Neurology. 2015;85:177–89.View ArticlePubMedPubMed CentralGoogle Scholar
  21. Sepúlveda M, Armangue T, Sola-Valls N, et al. Neuromyelitis optica spectrum disorders: comparative study according to the phenotype and serostatus. Neurol Neuroimmunol Neuroinflamm. (in press).Google Scholar
  22. Höftberger R, Sepulveda M, Armangue T, et al. Antibodies to MOG and AQP4 in adults with neuromyelitis optica and suspected limited forms of the disease. Mult Scler. 2015;21:866–74.View ArticlePubMedPubMed CentralGoogle Scholar
  23. Jiao Y, Fryer JP, Lennon VA, et al. Updated estimate of AQP4-IgG serostatus and disability outcome in neuromyelitis optica. Neurology. 2013;81:1197–204.View ArticlePubMedPubMed CentralGoogle Scholar
  24. Zamvil SS, Slavin AJ. Does MOG Ig-positive AQP4-seronegative opticospinal inflammatory disease justify a diagnosis of NMO spectrum disorder? Neurol Neuroimmunol Neuroinflamm. 2015;2:e62.View ArticlePubMedPubMed CentralGoogle Scholar
  25. Pittock S, Lucchinetti C. Neuromyelitis optica and the evolving spectrum of autoimmune aquaporin-4 channelopathies: a decade later. Ann N Y Acad Sci. 2015;doi: 10.1111/nyas.12794.
  26. Guo Y, Lennon VA, Popescu BF, et al. Autoimmune aquaporin-4 myopathy in neuromyelitis optica spectrum. JAMA Neurol. 2014;71:1025–9.View ArticlePubMedGoogle Scholar
  27. Verkman AS, Phuan PW, Asavapanumas N, Tradtrantip L. Biology of AQP4 and anti-AQP4 antibody: Therapeutic implications for NMO. Brain Pathol. 2013;23:684–95.View ArticlePubMedPubMed CentralGoogle Scholar
  28. Waters PJ, McKeon A, Leite MI, et al. Serologic diagnosis of NMO: A multicenter comparison of aquaporin-4-IgG assays. Neurology. 2012;78:665–71.View ArticlePubMedPubMed CentralGoogle Scholar
  29. Mckeon A, Lennon VA, Lotze T, et al. CNS aquaporin-4 autoimmunity in children. Neurology. 2008;71:93–100.View ArticlePubMedGoogle Scholar
  30. Banwell B, Tenembaum S, Lennon VA, et al. Neuromyelitis optica-IgG in childhood inflammatory demyelinating CNS disorders. Neurology. 2008;70:344–52.View ArticlePubMedGoogle Scholar
  31. Hacohen Y, Absoud M, Woodhall M, et al. Autoantibody biomarkers in childhood-acquired demyelinating syndromes: results from a national surveillance cohort. J Neurol Neurosurg Psychiatry. 2014;85:456–61.View ArticlePubMedGoogle Scholar
  32. Lotze TE, Northrop JL, Hutton GJ, Ross B, Schiffman JS, Hunter JV. Spectrum of pediatric neuromyelitis optica. Pediatrics. 2008;122:e1039–47.View ArticlePubMedGoogle Scholar
  33. Collongues N, Marignier R, Zéphir H, et al. Long-term follow-up of neuromyelitis optica with a pediatric onset. Neurology. 2010;75:1084–8.View ArticlePubMedGoogle Scholar
  34. Wang KC, Lin KH, Lee TC, et al. Poor responses to interferon-beta treatment in patients with neuromyelitis optica and multiple sclerosis with long spinal cord lesions. PLoS One. 2014;9:e98192.View ArticlePubMedPubMed CentralGoogle Scholar
  35. Min JH, Kim BJ, Lee KH. Development of extensive brain lesions following fingolimod (FTY720) treatment in a patient with neuromyelitis optica spectrum disorder. Mult Scler. 2012;18:113–5.View ArticlePubMedGoogle Scholar
  36. Kim SH, Jeong IH, Hyun JW, et al. Treatment outcomes with rituximab in 100 patients with neuromyelitis optica: Influence of FCGR3A polymorphisms on the therapeutic response to Rituximab. JAMA Neurol. 2015;72:989–95.View ArticlePubMedGoogle Scholar
  37. Pittock SJ, Lennon VA, McKeon A, et al. Eculizumab in AQP4-IgG-positive relapsing neuromyelitis optica spectrum disorders: An open-label pilot study. Lancet Neurol. 2013;12:554–62.View ArticlePubMedGoogle Scholar
  38. Araki M, Matsuoka T, Miyamoto K, et al. Efficacy of the anti-IL-6 receptor antibody tocilizumab in neuromyelitis optica: a pilot study. Neurology. 2014;82:1302–6.View ArticlePubMedPubMed CentralGoogle Scholar
  39. Hammer O. CD19 as an attractive target for antibody-based therapy. MAbs. 2012;4:571–7.View ArticlePubMedPubMed CentralGoogle Scholar
  40. Tradtrantip L, Zhang H, Saadoun S, et al. Anti-aquaporin-4 monoclonal antibody blocker therapy for neuromyelitis optica. Ann Neurol. 2012;71:314–22.View ArticlePubMedPubMed CentralGoogle Scholar
  41. Mader S, Gredler V, Schanda K, et al. Complement activating antibodies to myelin oligodendrocyte glycoprotein in neuromyelitis optica and related disorders. J Neuroinflammation. 2011;8:184.View ArticlePubMedPubMed CentralGoogle Scholar
  42. Baumann M, Sahin K, Lechner C, et al. Clinical and neuroradiological differences of paediatric acute disseminating encephalomyelitis with and without antibodies to the myelin oligodendrocyte glycoprotein. J Neurol Neurosurg Psychiatry. 2014;86:265–72.View ArticlePubMedGoogle Scholar
  43. Probstel AK, Dornmair K, Bittner R, et al. Antibodies to MOG are transient in childhood acute disseminated encephalomyelitis. Neurology. 2011;77:580–8.View ArticlePubMedGoogle Scholar
  44. Di Pauli F, Mader S, Rostasy K, et al. Temporal dynamics of anti-MOG antibodies in CNS demyelinating diseases. Clin Immunol. 2011;138:247–54.View ArticlePubMedGoogle Scholar
  45. Hacohen Y, Absoud M, Deiva K, et al. Myelin oligodendrocyte glycoprotein antibodies are associated with a non-MS course in children. Neurol Neuroimmunol Neuroinflamm. 2015;2:e81.View ArticlePubMedPubMed CentralGoogle Scholar
  46. Rostásy K, Mader S, Hennes EM, et al. Persisting myelin oligodendrocyte glycoprotein antibodies in aquaporin-4 antibody negative pediatric neuromyelitis optica. Mult Scler. 2013;19:1052–9.View ArticlePubMedGoogle Scholar
  47. Kitley J, Woodhall M, Waters P, et al. Myelin-oligodendrocyte glycoprotein antibodies in adults with a neuromyelitis optica phenotype. Neurology. 2012;79:1273–7.View ArticlePubMedGoogle Scholar
  48. Rostasy K, Mader S, Schanda K, et al. Anti–myelin oligodendrocyte glycoprotein antibodies in pediatric patients with optic neuritis. Arch Neurol. 2012;69:752–6.View ArticlePubMedGoogle Scholar
  49. Huppke P, Rostasy K, Karenfort M, et al. Acute disseminated encephalomyelitis followed by recurrent or monophasic optic neuritis in pediatric patients. Mult Scler. 2013;19:941–6.View ArticlePubMedGoogle Scholar
  50. Fernandez-Carbonell C, Vargas-Lowy D, Musallam A, et al. Clinical and MRI phenotype of children with MOG antibodies. Mult Scler. 2016;22:174–84.View ArticlePubMedGoogle Scholar
  51. Kitley J, Waters P, Woodhall M, et al. Neuromyelitis optica spectrum disorders with aquaporin-4 and myelin-oligodendrocyte glycoprotein antibodies: A comparative study. JAMA Neurol. 2014;71:1–8.Google Scholar
  52. Sato DK, Callegaro D, Lana-Peixoto MA, et al. Distinction between MOG antibodypositive and AQP4 antibody-positive NMO spectrum disorders. Neurology. 2014;82:474–81.View ArticlePubMedPubMed CentralGoogle Scholar
  53. Ikeda K, Kiyota N, Kuroda H, et al. Severe demyelination but no astrocytopathy in clinically definite neuromyelitis optica with anti-myelin-oligodendrocyte glycoprotein antibody. Mult Scler. 2015;21:656–9.View ArticlePubMedGoogle Scholar
  54. Srivastava R, Aslam M, Kalluri SR, et al. Potassium channel KIR4.1 as an immune target in multiple sclerosis. N Engl J Med. 2012;367:115–23.View ArticlePubMedGoogle Scholar
  55. Kraus V, Srivastava R, Kalluri SR, et al. Potassium channel KIR4.1-specific antibodies in children with acquired demyelinating CNS disease. Neurology. 2014;82:470–3.View ArticlePubMedGoogle Scholar
  56. Brickshawana A, Hinson A, Romero M, et al. Investigation of the KIR4.1 potassium channel as a putative antigen in patients with multiple sclerosis: a comparative study. Lancet Neurol. 2014;13:795–806.View ArticlePubMedPubMed CentralGoogle Scholar
  57. Nerrant E, Salsac C, Charif M, et al. Lack of confirmation of anti-inward rectifying potassium channel 4.1 antibodies as reliable markers of multiple sclerosis. Mult Scler. 2014;20:1699–703.View ArticlePubMedGoogle Scholar
  58. Brill L, Goldberg L, Karni A, et al. Increased anti-KIR4.1 antibodies in multiple sclerosis: could it be a marker of disease relapse? Mult Scler. 2015;21:572–9.View ArticlePubMedGoogle Scholar
  59. Filippi M, Rocca MA, Lassmann H. KIR4.1: another misleading expectation in multiple sclerosis? Lancet Neurol. 2014;13:753–5.View ArticlePubMedGoogle Scholar
  60. Armangue T, Leypoldt F, Dalmau J. Autoimmune encephalitis as differential diagnosis of infectious encephalitis. Curr Opin Neurol. 2014;27:361–8.View ArticlePubMedPubMed CentralGoogle Scholar
  61. Dalmau J, Lancaster E, Martinez-Hernandez E, Rosenfeld MR, Balice-Gordon R. Clinical experience and laboratory investigations in patients with anti-NMDAR encephalitis. Lancet Neurol. 2011;10:63–74.View ArticlePubMedPubMed CentralGoogle Scholar
  62. Titulaer MJ, McCracken L, Gabilondo I, et al. Treatment and prognostic factors for long-term outcome in patients with anti-NMDA receptor encephalitis: An observational cohort study. Lancet Neurol. 2013;12:157–65.View ArticlePubMedPubMed CentralGoogle Scholar
  63. Armangue T, Titulaer MJ, Málaga I, et al. Pediatric anti-N-methyl-D-aspartate receptor encephalitis-clinical analysis and novel findings in a series of 20 patients. J Pediatr. 2013;162:850–6. e2.View ArticlePubMedPubMed CentralGoogle Scholar
  64. Dalmau J, Gleichman AJ, Hughes EG, et al. Anti-NMDA-receptor encephalitis: case series and analysis of the effects of antibodies. Lancet Neurol. 2008;7:1091–8.View ArticlePubMedPubMed CentralGoogle Scholar
  65. Ramberger M, Bsteh G, Schanda K, et al. NMDA receptor antibodies: A rare association in inflammatory demyelinating diseases. Neurol Neuroimmunol Neuroinflamm. 2015;2:e141.View ArticlePubMedPubMed CentralGoogle Scholar
  66. Gresa-Arribas N, Titulaer MJ, Torrents A, et al. Antibody titres at diagnosis and during follow-up of anti-NMDA receptor encephalitis: a retrospective study. Lancet Neurol. 2014;13:167–77.View ArticlePubMedPubMed CentralGoogle Scholar
  67. Carvajal-González A, Leite MI, Waters P, et al. Glycine receptor antibodies in PERM and related syndromes: Characteristics, clinical features and outcomes. Brain. 2014;137:2178–92.View ArticlePubMedPubMed CentralGoogle Scholar
  68. Ariño H, Gresa-Arribas N, Blanco Y, et al. Cerebellar ataxia and glutamic acid decarboxylase antibodies: Immunologic profile and long-term effect of immunotherapy. JAMA Neurol. 2014;71:1009–16.View ArticlePubMedPubMed CentralGoogle Scholar
  69. Martinez-Hernandez E, Sepulveda M, Rostásy K, et al. Antibodies to aquaporin 4, myelin-oligodendrocyte glycoprotein, and the glycine receptor α1 subunit in patients with isolated optic neuritis. JAMA Neurol. 2015;72:187–93.View ArticlePubMedPubMed CentralGoogle Scholar


© Armangue et al. 2016