# Live Cell-Based Semi-Quantitative Stratification Highlights Titre-Dependent Phenotypic Heterogeneity in MOGAD: A Single-Centre Experience

## TL;DR

This study shows that measuring anti-MOG antibody levels in MOGAD patients helps identify different disease patterns and improves diagnosis.

## Contribution

The study introduces a semi-quantitative method to classify MOGAD patients based on antibody titre levels, revealing phenotypic heterogeneity.

## Key findings

- High-titre MOGAD patients tend to have optic neuritis and encephalic involvement.
- Low-titre patients more often show spinal cord syndromes and brainstem symptoms.
- Semi-quantitative fluorescence ratios reliably correlate with antibody titre levels.

## Abstract

Myelin oligodendrocyte glycoprotein antibody–associated disease (MOGAD) is an inflammatory demyelinating disorder of the central nervous system characterised by heterogeneous clinical and radiological presentations. Accurate interpretation of serum anti–myelin oligodendrocyte glycoprotein (anti-MOG) antibody titres is critical to improve diagnostic precision and prognostic assessment. This single-centre retrospective study evaluated 19 patients diagnosed with MOGAD in 2023, all of whom were seropositive for anti-MOG IgG, as confirmed by live cell-based assays (CBAs) using full-length human MOG and IgG1-specific secondary antibodies. Antibody quantification combined a ratiometric semi-quantitative fluorescence index with classical endpoint dilution titres, enabling classification into low, medium, and high titre groups. Stratification revealed titre-dependent phenotypic heterogeneity: high-titre patients were older at onset and predominantly presented with optic neuritis, often bilateral, and encephalic involvement, whereas low-titre patients more frequently exhibited spinal cord syndromes, cerebellar or brainstem symptoms, and a higher prevalence of cerebrospinal fluid-restricted oligoclonal bands. Semi-quantitative fluorescence ratios correlated consistently with endpoint titres, and exponential decay analysis demonstrated slower signal loss in high-titre sera, confirming assay reliability. No significant association emerged between titre level and monophasic versus relapsing disease course. Anti-MOG antibody titres could serve not only as a diagnostic biomarker but also to capture clinically relevant immunopathological diversity, supporting a titre-stratified approach to diagnosis and early prognostication. Incorporating semi-quantitative metrics alongside clinical and imaging features may refine the diagnostic algorithm and prevent misclassification of atypical presentations.