Novel FLAMES Presentation in Anti-MOG Encephalitis with FLAIR-Hyperintense Lesions
Juan Pablo Noriega1, Jaime Toro2, Jairo Gaitan Alfonso1, Maria Paula Zafra-Sierra2, Estefania Rojo - Bustamante2, Saul Reyes3
1Department of Neurology, Hospital Universitario−Fundación Santa Fe de Bogotá, 2School of Medicine, Universidad El Bosque, Bogotá, Colombia, 3Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
Background:
Myelin oligodendrocyte glycoprotein antibody-associated disease (MOGAD) is an inflammatory condition of the central nervous system, characterized by episodes of immune-mediated demyelination that commonly affect the optic nerves, brain, and spinal cord. While this disease predominantly affects children, it can present in adults with distinct clinical and radiographic features. FLAIR-hyperintense lesions in anti-MOG associated encephalitis with seizures (FLAMES) represent a clinicoradiographic sub-entity of MOGAD, distinguished by specific imaging findings and seizure activity.
Design/Methods:
A previously healthy 32-year-old male presented to the emergency room after experiencing bilateral tonic-clonic seizures with tongue biting and loss of consciousness. This was followed by a 40-minute period of postictal confusion and non-fluent aphasia.
Four days prior to this, the patient had exhibited brief hyperkinetic dystonic movements in the right cervical and facial region. Family members also reported notable behavioral changes, including irrelevant responses during conversations, prolonged latency in answering questions, and transient difficulty in communication. These behavioral symptoms lasted for approximately two weeks and then resolved spontaneously.
Neurological examination demonstrated non-fluent aphasia and motor deficits. MRI findings revealed precentral and postcentral leptomeningeal enhancement, along with FLAIR-hyperintense lesions, in line with a diagnosis of FLAMES. Cerebrospinal fluid analysis showed pleocytosis at 41 leukocytes/µL (reference rage <5/µ). The patient was treated with high-dose corticosteroids and remained seizure-free at the 6-month follow-up. Subsequent testing for anti-MOG antibodies returned positive, confirming the diagnosis of MOGAD, with FLAMES as the primary clinical and radiological presentation.
Conclusions:
This case highlights FLAMES as a rare but significant manifestation of MOGAD in adults. The combination of seizure activity, subtle behavioral changes, and FLAIR-hyperintense lesions underscores the importance of early recognition of this condition. Positive anti-MOG antibodies confirmed the diagnosis of MOGAD. Early intervention with high-dose corticosteroids resulted in a favorable outcome, reinforcing the need for prompt diagnosis and treatment to prevent long-term neurological complications.
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