Is a patient with Multiple Sclerosis (MS) indicated for admission for Lumbar Puncture (LP) to test for Oligoclonal Bands (OCBs) and Anti-Myelin Oligodendrocyte Glycoprotein (Anti-MOG) antibodies?

Lumbar Puncture for OCBs and Anti-MOG Testing in MS Patients

Patients with MS do not routinely require hospital admission for lumbar puncture to test for oligoclonal bands (OCBs) and anti-MOG antibodies, as these tests can typically be performed in outpatient settings. 1

Diagnostic Role of OCBs and Anti-MOG Testing in MS

Oligoclonal Bands (OCBs)

• OCBs are present in up to 98% of MS patients in Central/Northern Europe, though prevalence may be lower in Asian populations (40-80%) 1
• OCBs serve as a supportive diagnostic marker for MS but are not specific to MS alone
• OCBs are typically absent in MOG antibody-associated disease (MOGAD), found in only 12-13% of cases 2, 1

Anti-MOG Testing

• MOG antibody testing is NOT routinely indicated for typical MS patients 2, 1
• MOG-IgG is a biomarker for a distinct condition (MOGAD) that differs from MS in clinical presentation, imaging findings, and treatment response 1, 3
• Testing all MS patients for MOG-IgG would result in poor positive predictive value due to the low prevalence of MOGAD among MS patients 2

When to Consider MOG Antibody Testing

MOG antibody testing should be considered in patients with:

1. Atypical MS presentations:

   • Bilateral optic neuritis
   • Longitudinally extensive transverse myelitis
   • ADEM or ADEM-like presentations
   • Normal supratentorial MRI
   • Neutrophilic CSF pleocytosis or CSF white cell count >50/μl 2, 1

2. Imaging findings atypical for MS:

   • Absence of Dawson's finger lesions (present in 98.6% of true MS)
   • Absence of juxtacortical U fiber lesions
   • Absence of periventricular lesions typical of MS 2, 1

3. Laboratory findings atypical for MS:

   • Negative OCBs (OCBs present in only 12-13% of MOGAD cases)
   • CSF pleocytosis with neutrophils (found in 43% of MOGAD cases) 2, 1

4. Treatment response patterns:

   • Symptoms flaring after tapering of oral steroids
   • Poor response to typical MS therapies
   • Increased relapse rate with interferon-beta treatment 2, 1

Practical Approach to Testing

• Cell-based assays (IFT/FACS) are the gold standard for MOG antibody testing 2, 1
• Serum is the preferred specimen for MOG antibody testing 1, 3
• Lumbar puncture remains important for OCB testing in MS diagnosis but can typically be performed in outpatient settings 1

Important Considerations

• MOG antibody testing should not be restricted only to patients with AQP4-IgG-negative NMOSD, as this would miss many MOGAD cases 2
• Testing all MS patients for MOG antibodies is not recommended due to the risk of false positives in large unselected populations 2
• Early identification of MOGAD is important as some MS therapies may be ineffective or potentially harmful in these patients 1

Clinical Implications

• A positive MOG antibody test in a patient with MS-like presentation should prompt reconsideration of the diagnosis and treatment approach 1, 4
• MOGAD typically requires different treatment approaches than MS, including consideration of plasma exchange, IVIG, rituximab, or other immunosuppressive therapies 1, 4

In conclusion, while lumbar puncture for OCB testing is valuable in MS diagnosis, it typically doesn't require hospital admission, and MOG antibody testing should be reserved for patients with atypical features that raise suspicion for MOGAD rather than MS.