Escalating treatment of optic neuritis by repeated high-dose corticosteroid-therapies and plasma exchange in pediatric multiple sclerosis

Background: Severe relapses in adults with multiple sclerosis (MS), refractory to a single high-dose corticosteroid-treatment, are currently treated with an escalation design consisting of repetitive high-dose corticosteroid-therapies and, if relevant improvement is not achieved, with plasma exchange (PE). In relapsing-remitting (RR) pediatric MS, defined by onset before the age of 16 years, there is only one published case treated with PE for a steroid-refractory relapse before the age of 16 years. Objective: We report on two female pediatric RRMS patients with severe optic neuritis and insufficient or lacking response to a single high-dose corticosteroid-treatment. Methods: Both patients with severe optic neuritis were treated with an escalation regimen with PE after repetitive corticosteroid treatments. Results: Patient 1: A 14-year-old girl with RRMS developed a relapse with bilateral optic neuritis, visual acuity (VA) finger counting right eye (oculus dexter, OD), left eye (oculus sinister, OS) 0.02 (decimal equivalent). After the first high-dose corticosteroid-pulse (1g methylprednisolone i.v. daily over 5 days) VA improved to 0.05 on OD and 0.2 on OS, after the second (2g methylprednisolone i.v. daily over 5 days) to 0.2 OD and 0.8 OS. After a subsequent five PEs VA improved on OD to 0.5 and to 1.0 on OS. After 3 months VA was 1.0 on both eyes. Patient 2: An 11-year-old girl with RRMS developed optic neuritis on OS with a VA of 0.03. After two high-dose corticosteroid pulses (850mg prednisolone daily i.v. over 5 days, 1.7g pred-nisolone daily over 5 days) VA improved only slightly to 0.05. After a subsequent 5 PEs there was no further improvement. Treatments were well tolerated in both patients. Conclusions: These cases illustrate that the escalation design for relapse treatment used in adult MS patients is also well tolerated in pediatric MS. At least single pediatric MS patients may benefit from that regimen.