What is the best course of treatment for myelitis with constant pain and OCB positive type 2?

Management of Myelitis with Thoracic Lesion and OCB Type 2

Based on your clinical presentation of myelitis with a T6 lesion causing constant pain, normal motor and sensory function, and positive oligoclonal bands (OCB) type 2, you should undergo testing for MOG antibodies and receive high-dose intravenous methylprednisolone (1g/day for 3-5 days) as first-line treatment, followed by maintenance immunosuppressive therapy to prevent relapses.

Diagnostic Considerations

Your presentation suggests a possible MOG-IgG-associated encephalomyelitis (MOG-EM) that requires further investigation:

• The presence of OCB type 2 (positive in CSF but not serum) is atypical for MOG-EM but can occur in approximately 12-13% of MOG-EM cases 1
• Thoracic spinal cord lesion with pain but preserved motor function suggests inflammatory myelitis
• According to international recommendations, you meet criteria for MOG-IgG testing due to:
  • Myelitis with radiological findings compatible with CNS demyelination
  • OCB pattern that is uncommon in MOG-EM but doesn't exclude it 1

Testing to Consider:

1. MOG-IgG antibody testing using cell-based assays (current gold standard) 1
2. AQP4-IgG antibody testing to rule out neuromyelitis optica spectrum disorder (NMOSD)
3. Contrast-enhanced spinal MRI to evaluate lesion extent and characteristics
4. Brain MRI to look for additional lesions

Treatment Algorithm

Acute Phase Treatment:

1. High-dose intravenous methylprednisolone (1g/day for 3-5 days) as first-line treatment 2

   • Should be initiated as soon as possible, ideally within the first few hours
   • Critical for preventing long-term disability

2. If inadequate response to steroids within 1-2 weeks, consider:

   • Plasma exchange (5-10 sessions every other day) 2
   • Intravenous immunoglobulin (IVIG) at 2g/kg divided over 5 days 2

Maintenance Therapy:

• Essential as relapses occur in 50-60% of patients during corticosteroid tapering 2
• Options based on antibody status:
  • If MOG-IgG positive: Rituximab is preferred 3
  • If AQP4-IgG positive: Rituximab or cyclophosphamide 1, 2
  • If seronegative: Consider cyclophosphamide or other immunosuppressants 2

Pain Management:

• For neuropathic pain (your main symptom), consider:
  • Pregabalin (starting at 75mg twice daily, titrating up as needed)
  • Gabapentin (starting at 300mg daily, gradually increasing)
  • Duloxetine (60mg daily) 2

Monitoring and Follow-up

1. Regular neurological assessments to monitor for:

   • New neurological symptoms
   • Progression of existing symptoms
   • Treatment response

2. Follow-up MRI at 3-6 months to assess:

   • Resolution of inflammatory lesions
   • Development of new lesions

3. Repeat antibody testing (if initially positive) to monitor disease activity

Prognosis Factors

Your prognosis may be favorable due to:

• Normal motor and sensory function (preserved)
• Prompt medical attention
• Single lesion at T6 level

However, negative prognostic factors include:

• Constant pain suggesting ongoing inflammation
• Positive OCB which may indicate a more aggressive disease course 1

Important Considerations

• Early treatment is critical - delay in therapy initiation (>2 weeks) is associated with worse outcomes 2
• The presence of OCB type 2 is more common in multiple sclerosis than MOG-EM, so differential diagnosis must be carefully considered 1
• If MOG-IgG positive, aggressive treatment approach with plasma exchange (if resistant to steroids) followed by rituximab is recommended 3
• Flare-ups are common during steroid tapering, underscoring the need for maintenance therapy 2

This management approach prioritizes early aggressive treatment to minimize inflammation and prevent long-term disability while addressing your primary symptom of constant pain.