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The report by Matiello et al regarding a relapse of neuromyelitis optica (NMO) after autologous hematopoietic stem cell transplantation highlights the need to further understand the role of the immune system in this disease.1 Immunosuppressive therapeutics targeting B- and T-cells are utilized to prevent disabling relapses in NMO.2 Rituximab is a monoclonal anti-CD20 antibody that is reported to be effective in NMO.3 Alemtuzumab is a monoclonal anti-CD52 antibody with preliminary phase II data in multiple sclerosis, but not in NMO.4 We describe a patient with 20 relapses in 5 years despite sequential treatment with four immunomodulatory therapeutics in combination with corticosteroids and plasma exchange (PLEX) for relapses. She appeared to paradoxically worsen with profound weakness after B cell depletion with rituximab and developed tumefactive cerebral lesions after alemtuzumab.

Lack of Response to Monoclonal Antibody Therapy in Neuromyelitis Optica