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NMOSD – Steroid-Refractory Myelitis — SCE Neurology MCQ

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ModerateMultiple Sclerosis & CNS InflammationNMOSD – Steroid-Refractory MyelitisSCE Neurology

A 32-year-old woman presents with a 3-week history of bilateral leg weakness, urinary retention, and a sensory level at T4. MRI spine shows longitudinally extensive transverse myelitis from T2 to T7. MRI brain is normal. CSF shows 50 lymphocytes/µL, protein 1.0 g/L, no oligoclonal bands. AQP4 antibodies are positive. She is treated with IV methylprednisolone for 5 days but has no improvement. What is the next treatment step?

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Correct answer: B — Plasma exchange

In steroid-refractory acute attacks of AQP4+ NMOSD, plasma exchange (PLEX) is the recommended escalation therapy. NMOSD attacks are often more severe than MS relapses and less responsive to steroids alone. PLEX directly removes pathogenic AQP4 antibodies from the circulation. Early PLEX is associated with better outcomes. A: An oral taper alone is insufficient for a non-responding severe attack. C: A second course of IVMP may be tried but PLEX is the established escalation. D: Cyclophosphamide is not standard acute treatment. E: Rituximab is a long-term preventive therapy, not acute treatment.

Reference: ABN NMOSD Guidelines; EAN/EFNS NMO Guidelines (2014)