Neuro-immunology&nbsp;&nbsp;&nbsp;

Can you use leflunomide and rituximab in a patient with both multiple sclerosis and rheumatoid arthritis?

How do you interpret the results of oligoclonal bands ordered to evaluate for demyelinating disease in patients with brain MRI lesions of unclear etiology?

Does the number of bands matter in making the diagnosis? Does it make a difference whether isolated or also in the serum? How do you interpret other r...

If a patient develops itching with their first dose of Tysabri despite pre-treatment, does this indicate that further cycles of Tysabri are contraindicated or do you continue Tysabri at the next cycle?

What is your treatment approach to neurological Sjogrens disease with both peripheral neuropathy and transverse myelitis?

What is the practical application of serological MS disease activity testing (offered by Octave Bio) for patients with MS?

In a patient with presumed autoimmune encephalitis, would treating them with IVIG before getting a brain biopsy alter the pathological changes in a meaningful way?

How do you use optical coherence tomography in the diagnosis and management of patients with multiple sclerosis and related diseases?

Do you see a current or future clinical role of neurofilament light chain in the diagnosis or workup of multiple sclerosis?

How do you distinguish between primary progressive MS versus relapsing remitting MS with superimposed relapses in a newly diagnosed patient that is naive to treatment?

Are there emerging biomarkers that help distinguish the phenotypes in the absence of evaluation over time?

Do you send CSF or serum ACE levels in the workup of neurosarcoidosis?

If not, are there any serum or CSF tests you consider to be helpful?

How do you workup patients with neuropathy suspected to be secondary to sarcoid?

Is a biopsy or EMG helpful in confirming the etiology? What is the best treatment for sarcoid neuropathy?

When do you order SSEPs for evaluation of multiple sclerosis?

What do you consider when deciding to use a high-efficacy DMT as an initial treatment in multiple sclerosis?

What lab levels would lead you to consider switching DMTs for patients with MS on Fingolimod?

E.g., JC virus antibody titer, absolute lymphocyte count, etc.

Does management of NMDA receptor encephalitis change in a patient with HIV/AIDS?

How would you counsel about DMT options for disease-modifying therapy for a patient with multiple sclerosis and positive Hepatitis B surface antigen with negative HBV DNA PCR?

How do you dose steroids in neurosarcoidosis patients with a worsening clinical symptoms or MRI findings?

Do you treat with only an IV steroid pulse or do you use an oral steroid taper as well? How long of a taper do you typically use?

If a patient with relapsing remitting MS has comorbid Sjogren's syndrome and is on hydroxychloroquine (Plaquenil), how does that impact choice of DMT for MS?

In a patient with neurosarcoidosis who required infliximab for initially refractory symptoms but is now stable, how do you decide on the optimal time to de-escalate therapy?

When starting a patient with MS on a DMT, how frequently should MRIs be ordered to assess whether the treatment is effective?

When do you consider plasmapheresis instead of (or in addition to) IV steroids for patients with acute MS exacerbation?

What are some commonly missed diagnoses that should be considered in cases of otherwise seronegative yet steroid-responsive autoimmune encephalitis?

What would you recommend for a patient with MS on dimethyl fumarate with recent exacerbations including optic neuritis and new enhancing brain lesions who wishes to go on more intensive therapy such as a B-cell depletion but recently required treatment for shingles?

What is your workup for CSF studies when evaluating for possible CNS Lupus?

In addition, what formula do you use to calculate the IgG index?

How do you interpret the finding of identical bands in CSF and serum in patients being evaluated for MS?

How do you approach the treatment of biopsy proven ABRA (amyloid beta related angiitis)?

What is the diagnostic yield of working up suspected autoimmune encephalitis in patients with new onset behavioral disturbance without overt neurological deficits?

Anecdotally, the diagnostic yield in these patients seems quite low, yet autoimmune encephalitis is often invoked in such patients, particularly in th...

How do you approach the workup of transverse myelitis without any abnormality on spine MRI?

If a patient has classic TM symptoms but a normal MRI, are there specific causes you look for?

4 Answers available

At what absolute lymphocyte count do you consider alternative/discontinuing DMT in a patient with MS on fingolimod (or other S1P modulator)?

Should the schedule of disease modifying therapy medication administration be changed if patient has received high dose steroids for an MS exacerbation?

Do you discontinue or adjust azathioprine when a patient develops elevated MCV after starting it?

When it seems fairly certain that this is a drug effect is it something that can just be monitored or requires a change in approach?

How would you approach the treatment of erosive inflammatory arthritis (RA or SpA) in a patient with multiple sclerosis on ocrelizumab who has failed csDMARD therapy?

Does COVID-19 infection (and use of Paxlovid or other antivirals) affect your decision on timing of maintenance anti-CD20 mAb therapy (eg Rituxan, Ocrevus) in patients with multiple sclerosis?

How often do you monitor CD-19 counts and immunoglobulin levels in MS patients on B-cell depletion therapy?

How do you approach low IgG levels on these medications?

Do you recommend continuous antibiotic prophylaxis for patients on complement inhibitors such as eculizumab?

Do you just use antibiotic prophylaxis if therapy is started prior to meningococcal vaccination?

How do you approach DMT choice in a patient with MS with a history of cancer?

Based on this review (Melamed and Lee, PMID 31998289), patients with MS on several DMTs may be at higher risk for certain cancers. How does this play ...

What factors influence whether you treat a suspected flare of NMOSD (neuromyelitis optica spectrum disorder) with pulse dose steroids versus plasmaphereis?

For patients with MS on natalizumab, at what JC virus antibody titer do you consider switching DMTs?

How do you approach the symptomatic management of Lhermitte's phenomenon in a patient with MS?

What is your treatment approach for multiple sclerosis related fatigue?

How would you manage a patient with secondary progressive multiple sclerosis manifesting with increased neuropsychiatric manifestations (ex. psychosis) with no recent changes on brain MRI?

How do you approach a mildly positive finding on an autoimmune encephalitis panel when there is no other evidence of encephalitis (such as elevated CSF protein, abnormal imaging, or EEG findings)?

For example, a GAD65 Ab of 0.07 when the cut-off is 0.02. Does this answer change if you consider adult vs pediatric populations?

For a patient with high suspicion for NMDA receptor encephalitis, is there a role for giving rituximab along with methylprednisolone & IVIG (all three together) while the CSF anti-NMDAR antibodies are still pending?

Instead of waiting for the antibody test to result, if you have a high suspicion for NMDAR encephalitis, is there a role for giving rituximab alongsid...

When do you prescribe a steroid taper after the high dose IV course for a multiple sclerosis exacerbation?

In what patients would you consider adjunctive IVIG for Sjogren's-related neuropathy?

How long do you continue immunotherapy (ie rituximab) in patients with NMDAR encephalitis with initially severe disease but a good trajectory of recovery?

Would you consider spinal cord biopsy for an intramedullary cord lesion with disabling neurological deficits and no diagnosis despite a comprehensive workup?

What is the diagnostic yield and complication rate in your experience?

How do you approach the treatment of SREAT (steroid-responsive encephalopathy with autoimmune thyroiditis) after initial pulse dose steroids?

How do you approach the management of patients with one clinical demyelinating event and MOG+ antibody status?

Do you wait for a second clinical event or start immunomodulatory therapy right away?

How do you approach the timing of COVID-19 vaccination for patients with multiple sclerosis on B-cell depleting therapies?

How do you approach the management of acute attacks of MOGAD-associated optic neuritis?

Specifically, what do you do if there is minimal improvement with IV steroids and/or IVIG?

How has your use of B-cell depleting therapy for MS changed during the COVID-19 pandemic?

Are there any specific patient populations that you are no longer routinely recommending to start B-cell depleting medications? For example, are you l...

In those with a history of anti-NMDA encephalitis with identified teratoma s/p resection and clinical symptom improvement, is there a role for monitoring anti-NMDA antibody titer as a marker of disease recurrence?

Do you ever check antibodies against EBV as part of a workup for MS in a patient with white matter lesions of unclear etiology on MRI?

Based on the results of the recent longitudinal analysis linking EBV infection and MS (Bjornevik et al., PMID 35025605), can negative EBV antibodies (...

How long do you maintain a patient with seropositive Neuromyelitis Optica Spectrum Disorder on disease modifying therapy?

For example, a clinically stable patient on eculizumab, do you continue it indefinitely?

How do you approach transitioning MS patients from Ocrevus to Tysabri or vice versa?

When would you consider checking JC virus prior to initiating biologic therapy?

For patients with a new diagnosis of active secondary progressive multiple sclerosis (SPMS) without prior trials of disease-modifying therapy, do you treat with siponimod or do you start with a different DMT?

Which method do you prefer to assess for stigmata of old optic neuropathy?

Ex. optical coherence tomography, visual-evoked potentials

What is your steroid-sparing agent of choice to treat GCA given the current tocilizumab shortage?

Thoughts on sarilumab vs methotrexate, or just treat with steroids alone

What is your approach to checking serum vWF antigen levels in adult patients with CNS vasculitis for monitoring disease activity?

Small study in pediatric PACNS have evaluated this as a potential marker (Cellucci et al., PMID 22740622)

In women of childbearing age with NMDA encephalitis and normal pelvic imaging, is there a role for oophorectomy for possible microteratoma?

If not, how often do you repeat pelvic imaging?

When do you consider discontinuing disease modifying therapies for multiple sclerosis?

How do you approach the diagnosis of MS subtypes like Balo's concentric sclerosis?

Do you approach things differently if a rare variant like this is suspected? Is the Balo's subtype more similar to RRMS or PPMS?

How do you treat paroxysmal phenomena such as paroxysmal dysarthria or dyskinesia in multiple sclerosis?

Should patients with clinically isolated syndrome be started on medication?

Do you treat HIV/AIDS-associated CNS vasculitis with antiretrovirals alone or in combination with steroids?