Advancements in the Care of Pediatric Neuroinflammatory Disorders (Podcast)

Amidst major breakthroughs in advanced imaging techniques, molecular biology and genetics, the advent of a new global pandemic catapulted the field of neuroimmunology into the limelight. This has helped turn pediatric neuroinflammatory disorders like autoimmune encephalitis into major topics of interest.

One such entity is pediatric-onset multiple sclerosis (POMS), which constitutes 5% to 10% of all MS cases, although actual numbers are likely much higher. Unlike adult MS, POMS presents almost exclusively in its relapsing-remitting form. In 2018, the drug fingolimod became the first disease-modifying therapy (DMT) approved for use in POMS. Additional clinical trials are underway exploring the safety and efficacy of other adult DMTs for use in the pediatric population.

“Pediatric neuroimmunology is a fast-moving, rapidly emerging field,” says Aaron W. Abrams, MD, a pediatric neurologist and neuroimmunologist in Cleveland Clinic’s Center for Pediatric Neurosciences and the Mellen Center for Multiple Sclerosis. “We have come a long way in the past 10 to 15 years, but we have a lot more work to do.”

In the latest episode of Cleveland Clinic’s Neuro Pathways podcast, Dr. Abrams discusses how pediatric and adult neuroimmunologists are moving the field forward. He shares insights on:

• Identifying demyelinating and neuroimmunologic disease in children
• Advancements in diagnostic tools, including biomarkers and MRI technology
• The importance of neuropsychological evaluation for pediatric patients
• Prospective therapies and clinical trials for children with MS
• The potential for early treatment to improve outcomes and prevent further neurological dysfunction

Click the podcast player above to listen to the 22-minute episode now, or read on for an edited excerpt. Check out more Neuro Pathways episodes at clevelandclinic.org/neuropodcast or wherever you get your podcasts.

Excerpt from the episode

Podcast host Glen Stevens, DO, PhD: What have we learned about managing pediatric MS that’s different from managing MS in adults?

Dr. Abrams: Pediatric MS, when it initially presents, is typically more highly inflammatory at the time of the clinical event. When we do imaging or we do cerebrospinal fluid analysis of patients with a first onset of demyelination in the pediatric age group, we tend to see a higher degree of inflammation. That is evidenced both by higher cell counts and higher protein levels in the cerebrospinal fluid and by more extensive lesions, as well as by enhancement patterns within MRI and neuroimaging techniques.

One of the very interesting things about pediatrics — and we think this may have to do to some extent with plasticity and the ability of young pediatric brains to bounce back from neurological insults — is that they seem to recover much better and faster than a lot of their adult counterparts. Even though the initial event is oftentimes more highly inflammatory and potentially more severe, pediatric patients often will actually recover much better.

Another important difference between pediatric and adult MS is that, with entities like MOG — or myelin oligodendrocyte glycoprotein-associated disease — pediatric patients are more likely to have a monophasic course. That means they’re more likely to have one relatively significant clinical event but then may not have any further clinical events. In contrast, their adult counterparts are more likely to have multiple events.

A final big difference is that pediatric MS almost always presents in a relapsing or remitting form, whereas adult MS can present initially as primary progressive or as relapsing-remitting and then can transform into secondary progressive. Pediatric MS is unique in the sense that it almost always presents in a relapsing-remitting form and then can transition to these other entities much later on in life, but it’s much, much less likely.