Is a patient with Multiple Sclerosis (MS) indicated for a lumbar puncture (LP) for Oligoclonal Bands (OCBs) and Anti-Myelin Oligodendrocyte Glycoprotein (Anti-MOG) testing?

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

Lumbar puncture for oligoclonal bands (OCBs) testing is indicated in MS patients when the diagnosis is uncertain, while Anti-MOG testing is only indicated when specific clinical features suggest MOG-associated disease rather than typical MS. 1

Indications for OCB Testing in MS

OCB testing via lumbar puncture is particularly valuable in the following scenarios:

• When MRI findings are insufficient to demonstrate dissemination in space
• When a patient presents with a single clinical attack and limited MRI findings
• In cases of suspected primary progressive MS, where OCBs can substitute for MRI criteria of dissemination in space 1

OCBs are present in 90-98% of MS patients in Central and Northern Europe, making them a crucial diagnostic marker that helps distinguish MS from other neurological disorders. Their absence in a suspected MS case should prompt consideration of alternative diagnoses. 1

Anti-MOG Testing Indications

Anti-MOG testing is NOT routinely indicated in typical MS cases but should be considered when:

• Patient presents with optic neuritis (especially bilateral) and absence of CSF-restricted OCBs 2, 3
• MRI findings are atypical for MS (e.g., normal brain MRI, absence of periventricular lesions) 4
• Patient shows poor response or worsening with typical MS treatments like IFN-beta or natalizumab 4

Diagnostic Algorithm

1. For patients with typical MS presentation:

   • If McDonald criteria are fully met with MRI findings, OCB testing may not be necessary
   • If diagnosis is uncertain, perform LP for OCB testing
   • Anti-MOG testing is not routinely indicated

2. For patients with atypical features:

   • Perform LP for OCB testing
   • Consider Anti-MOG testing if:
     • OCBs are absent (only 12-13% of MOG-EM patients have OCBs vs. 90-98% in MS) 1
     • Patient presents with severe optic neuritis or bilateral optic neuritis 4, 2
     • MRI shows atypical features for MS 4

Important Considerations

• Timing of steroid treatment does not appear to affect OCB results, so LP can be performed even after initiating steroids 5
• The presence of CSF-restricted OCBs is strongly associated with MS (present in only 12.5% of MOG-Ab+ patients vs. 61.7% of MOG-Ab- patients) 2
• OCB positivity correlates with higher disease burden in MS but is more valuable as a diagnostic marker than as a prognostic indicator 1

Common Pitfalls to Avoid

• Failing to test for MOG antibodies in patients with optic neuritis and absent OCBs (this combination strongly suggests MOG-EM rather than MS) 2
• Over-reliance on OCB status alone for diagnosis without considering clinical and MRI findings
• Not retesting borderline positive MOG-IgG results, which can lead to misdiagnosis 3
• Assuming that all demyelinating diseases have the same pathophysiology and treatment approach

The technical approach for OCB detection should use isoelectric focusing in agarose gels followed by immunoblotting, with paired CSF and serum samples analyzed without dilution for optimal sensitivity 1.