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neuro.mogad.v1

Myelin Oligodendrocyte Glycoprotein-Antibody Associated Disease (MOGAD)

neurologychronicsubacuteadultpediatricpregnancyoutpatientinpatientmixed
Start encounter →Print handoutPRODUCTION

Phase C shard-3 neuro wave-11 (2026-05-15): authored at SCAFFOLDED — no MOGAD-specific workup in clinical-tools-registry.ts (only workup.ms_flare registered for the shared steroid + PLEX/IVIG pulse). 8 phenotypes: classic_bilateral_ON_MOGAD / acute_TM_MOGAD / pediatric_ADEM_phenotype / brainstem / cortical_encephalitis / recurrent_disease_15_30pct / monophasic_course_70pct / pregnancy. 5 setting playbooks: home (slow taper supervision + relapsing DMT adherence + pediatric developmental surveillance) → outpatient (MS-NMO-MOGAD clinic q3-6 mo) → ed (acute relapse + MOG-IgG sample BEFORE steroid + HSV PCR if cortical encephalitis) → inpatient (IV pulse + IVIG + PLEX + slow 8-12 wk oral taper) → icu (cortical encephalitis with status, cervical myelitis with respiratory failure, ADEM coma). 8 PMID evidence anchor: Banwell MOGAD 2023 (36706773) + autoimmune mimics (34664709) + Wingerchuk NMOSD pivot (26092914) + cladribine MS-spectrum (30785074) + rituximab MOGAD (33219036) + MOGAD acute Rx (27793206) + Apoly DS PLEX (21242498) + Lyme CDC (33257476). Schema-blocked: calc.edss / workup.mog_igg_cba / workup.cortical_encephalitis_panel / workup.aqp4_igg_index / workup.mog_titer — not in clinical-tools-registry; surfaced in depth bundle. Critical safety: MOG-IgG via LIVE CBA only (ELISA = false positives); sample MOG BEFORE steroid; SLOW 8-12 wk oral prednisone taper to prevent rebound (MOGAD distinguishing feature); do NOT initiate chronic DMT after monophasic event (70% monophasic); AVOID typical MS DMTs (limited data; possible harm); HSV PCR MANDATORY if cortical encephalitis phenotype; pediatric methylpred 30 mg/kg/d (max 1 g). Sibling differentiation routes to neuro.ms-flare.core.v1 (acute pulse shared scaffolding; DMT diverges), neuro.transverse-myelitis.v1 (TM pivot), neuro.encephalitis.hsv.v1 (cortical encephalitis HSV mimic), neuro.nmosd.v1 (AQP4 distinct same-commit peer), neuro.adem.v1 (pediatric ADEM phenotype same-commit peer). Promotion to INTEGRATED requires registered MOGAD workup (e.g., workup.mog_igg_cba, workup.cortical_encephalitis_panel) + MOG-IgG live CBA cascade in clinical-tools-registry.

Entry points (9)

  • symptom
    MOG-IgG positive (live cell-based assay) with ≥1 core clinical event per Banwell 2023 (PMID 36706773)
    mog_igg_positive_with_core_event
  • symptom
    Bilateral simultaneous ON with severe vision loss + good steroid response — adult MOGAD typical (Banwell 2023 PMID 36706773)
    classic_bilateral_optic_neuritis_mogad
  • symptom
    Acute TM (often conus involvement, short or long-segment; MOG-IgG+ pivot from TM engine)
    acute_transverse_myelitis_mogad
  • symptom
    Pediatric encephalopathy + multifocal demyelination + MOG-IgG+ — ADEM-like presentation common in pediatric MOGAD (~60%)
    pediatric_adem_phenotype_mogad
  • symptom
    Brainstem syndrome (oculomotor, ataxia, dysphagia, dysarthria) with characteristic MOG-IgG-typical lesion
    brainstem_mogad
  • symptom
    Cortical encephalitis — seizures + FLAIR cortical hyperintensity (newer MOGAD recognition; Banwell 2023 PMID 36706773)
    cortical_encephalitis_mogad
  • symptom
    Cerebral monofocal syndrome with MOGAD-typical lesion
    cerebral_monofocal_mogad
  • history
    Recurrent MOGAD ≥2 events ≥3 mo apart → relapsing course (15-30% of MOGAD)
    recurrent_demyelinating_events_15_30pct
  • history
    Pregnancy + known MOGAD — relapse risk may increase postpartum
    pregnancy_in_known_mogad

Required inputs (16)

  • agerequired
    demographic • used at CONTEXT
    Bimodal — pediatric peak (5-10 y) presents ADEM-like; adult peak (30s-40s) presents ON + myelitis + cortical encephalitis (Banwell 2023 PMID 36706773)
  • sex
    demographic • used at CONTEXT
    MOGAD slightly female predominant (~3:2 adult); pediatric balanced (Banwell 2023 PMID 36706773)
  • symptom_onset_and_relapse_historyrequired
    history • used at FRAME
    70% monophasic with single attack + recovery; 15-30% relapsing — DMT decision driven by course (Banwell 2023 PMID 36706773; PMID 33219036)
  • mog_igg_serum_live_cell_based_assayrequired
    lab • used at INITIAL_WORKUP
    MOG-IgG via LIVE cell-based assay (live cell CBA) — gold standard; fixed cell CBA acceptable; ELISA NOT acceptable (false positives); clear positive titer (low-titer borderline) (Banwell 2023 PMID 36706773)
  • aqp4_igg_serum_cell_based_assayrequired
    lab • used at BRANCHING_WORKUP
    Distinguish from NMOSD-AQP4+ — different DMT; AQP4-IgG via CBA; mutually exclusive in 99% (Wingerchuk 2015 PMID 26092914)
  • mri_brain_orbit_with_gadrequired
    imaging • used at INITIAL_WORKUP
    STAT MRI brain + orbits + cord with gad; MOG-IgG-typical: bilateral ON (often longitudinally extensive optic nerve); fluffy peripheral cord lesion (conus prone); ADEM-like multifocal; cortical encephalitis FLAIR hyperintensity (Banwell 2023 PMID 36706773)
  • mri_cord_with_gad_for_myelitisrequired
    imaging • used at INITIAL_WORKUP
    Cervical + thoracic cord with gad — MOGAD myelitis often conus + central gray matter; some longitudinally extensive ≥3 segments (overlap with NMOSD pattern)
  • lp_csf_cell_count_protein_ocb_igg_indexrequired
    lab • used at INITIAL_WORKUP
    CSF — pleocytosis (often >50 cells); protein elevated; OCB usually NEGATIVE (vs MS 90%+ positive); intrathecal MOG-IgG (CSF-MOG) supports MOGAD if serum borderline (Banwell 2023 PMID 36706773)
  • hsv_pcr_viral_panel_csfrequired
    lab • used at BRANCHING_WORKUP
    Cortical encephalitis MOGAD overlaps differential with HSV encephalitis (route to neuro.encephalitis.hsv.v1) — HSV PCR + VZV + enterovirus + autoimmune AE panel MANDATORY
  • autoimmune_ae_panel_nmda_lgi1_caspr2_gad
    lab • used at BRANCHING_WORKUP
    Cortical encephalitis differential — autoimmune encephalitis panel (NMDAR / LGI1 / CASPR2 / GAD65 / GABA-B / AMPA)
  • pregnancy_testrequired
    lab • used at TREATMENT
    Required before DMT initiation in reproductive-age females
  • hepatitis_b_vzv_tb_screenrequired
    lab • used at TREATMENT
    Rituximab / B-cell depletion pre-screen
  • recent_infection_or_vaccinationrequired
    history • used at CONTEXT
    Post-infectious / post-vaccination MOGAD recognized (often ADEM-phenotype pediatric) — document precipitant
  • autoimmune_disease_history
    history • used at CONTEXT
    MOGAD comorbid autoimmunity less common than NMOSD; document if SLE/Sjögren/thyroid/RA
  • seizure_or_encephalopathyrequired
    symptom • used at RED_FLAGS
    Cortical encephalitis MOGAD — seizure + AMS + FLAIR cortical hyperintensity; AED initiation + EEG
  • visual_acuity_baselinerequired
    symptom • used at RISK_STRATIFICATION
    Severe ON baseline VA + steroid response trajectory drives PLEX trigger

12-phase flow (12)

  1. 1FRAME
    Confirm MOGAD per Banwell 2023 criteria (PMID 36706773) — MOG-IgG+ (live CBA) with ≥1 core clinical event + supporting MRI features + exclusion of alternatives (AQP4-IgG negative; HSV PCR negative if cortical encephalitis phenotype)
    inputs: symptom_onset_and_relapse_history
    advance: MOGAD phenotype assigned + monophasic vs relapsing tier
  2. 2ENTRY
    Acute core event (ON / myelitis / ADEM / cortical encephalitis / brainstem / cerebral monofocal) → acute pathway; established MOGAD on DMT → chronic management; pediatric ADEM phenotype → coordinate with neuro.adem.v1
    inputs: age, sex
    advance: Pathway selected (acute vs chronic vs specialty)
  3. 3CONTEXT
    Capture recent infection/vaccination (post-infectious ADEM-phenotype precipitant), prior DMT exposure, comorbid autoimmunity, pregnancy status, vaccination status
    inputs: recent_infection_or_vaccination, autoimmune_disease_history
    advance: MOGAD-relevant context captured
  4. 4RED_FLAGS
    Cortical encephalitis with new seizures / status epilepticus → STAT MRI + EEG + AED; severe bilateral ON with NLP → PLEX urgency for vision recovery; cervical myelitis with respiratory failure → ICU; ADEM-phenotype with coma → ICU
    inputs: seizure_or_encephalopathy
    actions: workup.ms_flare
    advance: Critical airway / vision / seizure escalation triaged
  5. 5INITIAL_WORKUP
    MOG-IgG (live CBA) + AQP4-IgG (CBA) — BEFORE steroid if feasible; STAT MRI brain + orbits + cord with gad; LP (cell count, protein, OCB, IgG index, HSV/VZV PCR if cortical encephalitis); CBC + CMP + LFT + glucose + pregnancy test; ESR + CRP; EEG if seizure (Banwell 2023 PMID 36706773)
    inputs: mog_igg_serum_live_cell_based_assay, mri_brain_orbit_with_gad, mri_cord_with_gad_for_myelitis, lp_csf_cell_count_protein_ocb_igg_index
    actions: panel.csf, panel.cbc, panel.renal, panel.lft, panel.inflammation
    advance: MOG-IgG status pending or returned + MRI complete + HSV-PCR pending if encephalitis
  6. 6BRANCHING_WORKUP
    AQP4-IgG → NMOSD pivot (neuro.nmosd.v1) if positive; HSV PCR → encephalitis pivot (neuro.encephalitis.hsv.v1) if positive; autoimmune encephalitis panel (NMDAR/LGI1/CASPR2/GAD/GABA-B/AMPA) if cortical encephalitis phenotype; paraneoplastic panel if older + atypical; CSF MOG-IgG (intrathecal) if serum borderline
    inputs: aqp4_igg_serum_cell_based_assay, hsv_pcr_viral_panel_csf, autoimmune_ae_panel_nmda_lgi1_caspr2_gad
    advance: Etiology classified (MOGAD definite / NMOSD pivot / HSV pivot / autoimmune AE)
  7. 7DIFFERENTIAL
    MOGAD ON / MOGAD TM / MOGAD ADEM-phenotype / MOGAD cortical encephalitis / MOGAD brainstem / NMOSD-AQP4 (pivot) / MS (McDonald 2017) / HSV/VZV encephalitis (pivot) / autoimmune AE (anti-NMDAR/LGI1) / ADEM without MOG / paraneoplastic / sarcoid / SLE / Behçet
    advance: Final phenotype assigned with confidence
  8. 8RISK_STRATIFICATION
    Course classification (70% monophasic vs 15-30% relapsing); severity of index event (visual acuity, ASIA, encephalopathy); MOG-IgG titer (persistence over time correlates with relapse risk); cortical encephalitis seizure burden (Banwell 2023 PMID 36706773)
    inputs: visual_acuity_baseline
    advance: Monophasic vs relapsing tier + DMT decision approached
  9. 9TREATMENT
    ACUTE: IV methylprednisolone 1 g/d × 3-5 d (often very steroid-responsive ~80% remit; PMID 27793206); IVIG 2 g/kg over 2-5 d for steroid-incomplete or pediatric ADEM; PLEX 5 sessions q48h for severe steroid-refractory (Apoly DS PMID 21242498); slow oral prednisone taper over 8-12 wk to PREVENT REBOUND. CHRONIC (only if relapsing course confirmed): rituximab 1 g IV × 2 q6 mo (PMID 33219036); OR AZA 2-3 mg/kg PO daily; OR MMF 1-3 g/day; OR IVIG-maintenance monthly. AVOID typical MS DMTs (limited data; some signal of harm).
    inputs: pregnancy_test, hepatitis_b_vzv_tb_screen
    advance: Acute pulse + DMT decision (monophasic = none; relapsing = biologic/IS)
  10. 10DISPOSITION
    Admit neurology for any acute relapse with deficit; ICU if cortical encephalitis with status epilepticus / ADEM-coma / cervical myelitis with respiratory failure; outpatient infusion suite for chronic rituximab/IVIG-maintenance; MS-NMO-MOGAD specialty clinic q3-6 mo
    advance: Disposition documented
  11. 11MONITORING
    Daily neuro exam during acute admission; EEG monitoring if cortical encephalitis; CBC + CD19/CD20 + IgG q3-6 mo on rituximab; LFT + CBC on AZA/MMF; MOG-IgG persistence at 6-12 mo (high-titer persistence correlates relapse risk); annual MRI brain + cord + orbits
    actions: panel.cbc, panel.lft, panel.renal
    advance: Monitoring schedule active
  12. 12FOLLOWUP
    Rehab (PT/OT/SLP); ophthalmology q3-6 mo if ON; neuropsych if cortical encephalitis or ADEM-phenotype (cognitive deficits); pediatric developmental surveillance if pediatric ADEM; AED management if seizure history; pregnancy planning + postpartum surveillance; MS-NMO-MOGAD specialty clinic q3-6 mo
    advance: Long-term plan + specialty referrals documented