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Aug 2012

Is It Too Early to Predict the Failure of Natalizumab in NMO?—Reply

Author Affiliations

Author Affiliations: Department of Neurology, St Josef-Hospital, Ruhr University Bochum, Bochum (Drs Kleiter and Hellwig); Department of Neurology, Klinikum rechts der Isar, Technische Universität München (Dr Berthele); Institute for Clinical Neuroimmunology, Ludwig-Maximilians-University (Dr Kümpfel), Munich; Department of Neurology, Friedrich-Alexander University Erlangen, Erlangen (Dr Linker); Multiple Sclerosis Center, Department of Neurology, Heinrich-Heine-University Düsseldorf, Düsseldorf (Drs Hartung and Aktas); and NeuroCure Clinical Research and Clinical and Experimental Multiple Sclerosis Research Center, Charité University Medicine, Berlin (Dr Paul), Germany.

Arch Neurol. 2012;69(8):1085-1086. doi:10.1001/archneurol.2012.1316

In reply

We appreciate Drs Govindarajan and Salgado describing a NMO IgG antibody–positive patient who had a 6-year course of clinical stability under natalizumab before becoming progressive. While such a long period with a good treatment response to natalizumab is noteworthy, several aspects of this patient are untypical for neuromyelitis optica (NMO). Only 13.7% of patients are older than 60 years at disease onset,1 8% have an elevated IgG index, and 16.4% show oligoclonal bands.2 Disease progression without relapses is uncommon in NMO,3 and it remains unclear whether optic neuritis was present, completing the full picture of NMO. In a patient with untypical clinical presentation, the verification of aquaporin 4 antibodies is of particular importance to make the diagnosis of NMO. Diagnostic tests applied to measure aquaporin 4 antibodies vary considerably regarding sensitivity and specificity, and immunohistochemical methods to detect NMO IgG additionally depend on the experience of the examiner.4