Myelin oligodendrocyte glycoprotein antibody-associated disease (MOGAD) has emerged as a significant etiology of acquired CNS demyelinating syndromes. While the clinical features are well established in adults, the presentation can be confusing and require extensive investigations in the pediatric population. We present two cases diagnosed with MOGAD, highlighting their unusual clinical and imaging manifestations.

MOGAD in pediatric patients presents various clinical manifestations, including optic neuritis, ADEM, less common like cortical encephalitis, and aseptic meningitis, which can complicate the diagnosis. Detecting anti-MOG IgG antibodies is central, and prompt recognition and intervention are essential for improving outcomes. Overlap with conditions like MS and NMOSD highlights the necessity for ongoing research and refining diagnostics.

Case 1: Encephalomyelitis with elevated MOG antibody

An 8-year-old male presented with 9 days of intractable vomiting, lethargy, and urinary incontinence after a recent Group A streptococcal infection. Brain MRI showed restricted diffusion over the right hemisphere with T2 hyperintensity. Spine MRI showed T2 hyperintensity with enhancement in the cervical and thoracic spinal cord. CSF studies showed elevated opening pressure, lymphocytic pleocytosis, and elevated protein. The Anti-MOG titer was 1:10000. Patients responded well to pulse steroids. 

Case 2: Transverse myelitis with positive Lyme and MOG antibodies 

A 17-year-old previously healthy male presented with acute onset bilateral leg weakness, numbness, tingling, urinary retention, and constipation. Examination revealed diminished sensation below mid thorax (T5). MRI showed T2 hyperintensity in the thoracic and lumbar spinal cord. Lyme serology was positive, and the patient received 2 weeks of doxycycline and high-dose IV methylprednisolone. CSF showed mild lymphocytic pleocytosis. Anti-MOG titer was 1:1000 and the patient received oral steroids taper with rapid improvement.

MOGAD should be considered in the differential diagnosis and antibody titer should be ordered earlier if neuroimaging suspicious of demyelination in children with unusual neurological signs.