title: Neuromyelitis optica presenting with relapses under treatment with natalizumab: a case report.
abstract: BACKGROUND
  Neuromyelitis optica is an inflammatory demyelinating disease of the central nervous system. To date, optimal therapeutic approaches for neuromyelitis optica have yet to be defined. Natalizumab is highly effective in relapsing-remitting multiple sclerosis and might be considered as an option.
  
  
  METHODS
  Here, we describe a 67-year-old Caucasian man with definite neuromyelitis optica with detection of anti-aquaporin-4 antibodies over the course of the disease. After initially discussing the diagnosis of multiple sclerosis at an outside hospital, our patient received interferon beta 1a as well as repeated corticosteroid pulses without success. Under subsequent therapy with natalizumab, he continued to present relapses. It was not until discontinuation of natalizumab, repeated cycles of plasma exchanges and initiation of therapy with rituxan that the disease course started to stabilize. Although B cells were completely depleted, our patient experienced another severe myelitis relapse during further follow-up and an additional immunosuppressive therapy with cyclophosphamide was started. Under this regimen, no further relapses occurred over the next 24 months.
  
  
  CONCLUSIONS
  This case adds further evidence to the previously discussed notion that natalizumab, while highly effective in multiple sclerosis, may not work sufficiently in neuromyelitis optica. It further advocates for repetitive testing of anti-aquaporin-4 antibodies before and after treatment initiation.
authors.affiliation: Department of Neurology, Friedrich-Alexander University of Erlangen-Nuremberg, Schwabachanlage 6, 91054 Erlangen, Germany. De-Hyung.Lee@uk-erlangen.de.
authors.forename: De-Hyung
authors.initials: DH
authors.lastname: Lee
authors.forename: Alexandra B
authors.initials: AB
authors.lastname: Laemmer
authors.forename: Anne
authors.initials: A
authors.lastname: Waschbisch
authors.forename: Tobias
authors.initials: T
authors.lastname: Struffert
authors.forename: Christian
authors.initials: C
authors.lastname: Maihöfner
authors.forename: Stefan
authors.initials: S
authors.lastname: Schwab
authors.forename: Ralf Andreas
authors.initials: RA
authors.lastname: Linker
mesh_terms: D000368:Aged; D061067:Antibodies, Monoclonal, Humanized / Q000627:therapeutic use*; D058846:Antibodies, Monoclonal, Murine-Derived / Q000627:therapeutic use; D006801:Humans; D007155:Immunologic Factors / Q000627:therapeutic use*; D008297:Male; D000069442:Natalizumab; D009471:Neuromyelitis Optica / Q000188:drug therapy*; D010951:Plasma Exchange; D012008:Recurrence; D000069283:Rituximab; D017211:Treatment Failure
chemical_list: D061067:Antibodies, Monoclonal, Humanized; D058846:Antibodies, Monoclonal, Murine-Derived; D007155:Immunologic Factors; D000069442:Natalizumab; D000069283:Rituximab