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Neuromyelitis optica spectrum disorder (NMOSD): Suspect-and-test checklist for clinicians

A one-page worksheet that turns the full Neuromyelitis optica spectrum disorder (NMOSD) diagnosis guide into something you can use at the point of care: what to look for, what to order, which results should not end the workup, and who else to test or refer.

Who it is forClinicians and care teams who may see Neuromyelitis optica spectrum disorder (NMOSD) before it is diagnosed, including primary care, the specialists named in the guide, and referral or genetics coordinators.
When to use itWhen Neuromyelitis optica spectrum disorder (NMOSD) is on the differential, when a patient has several red flags, or when you are preparing a referral or a second opinion.

How to use it, section by section

  1. Red flags present: Tick each finding the patient has. They are grouped by body system so you can scan quickly.
  2. Already labeled as: Tick earlier diagnoses on the chart that the sources say are often given first.
  3. Family to test: Note relatives who may need testing, and record when symptoms began and which specialists have already been seen.
  4. Testing, in order: Tick each test as you order it and write the result on its line. The order follows the published sources.
  5. Results that do not rule it out: A reminder of findings that can look reassuring but do not exclude Neuromyelitis optica spectrum disorder (NMOSD).
  6. Specialists: Tick the referral, then write who it went to and any notes.
Two ways to fill it inPrint it blank and write on it, or tick boxes and type on this screen first, then print or save as a PDF. Keep it with the chart or send it with the referral.
PrivacyNothing you type is sent or saved. It stays in this browser tab and disappears when you close it. Use patient initials, not full identifiers.

What it is not: Not a diagnostic score, a protocol or coding advice. It summarizes published sources, and clinical judgment and the treating clinician govern. Every point is sourced in the full Neuromyelitis optica spectrum disorder (NMOSD) guide.

One Letter page. Use your browser's print or save as PDF.Full guide with sources
Suspect-and-test checklist
Neuromyelitis optica spectrum disorder (NMOSD)

Antibody-mediated CNS disease, often first labeled MS. Serum AQP4-IgG by cell-based assay is the key test, ideally drawn before treatment.

ICD-10-CMG36.0Trial Friend for Clinicians

1Red flags present

Eye

Spinal cord

Gut and brainstem

Other brain

Who

CSF and MRI against MS

2Already labeled as

3Family to test

4Testing, in the order the sources describe

  1. Serum AQP4-IgG, cell-based assayAny 1 of the 6 core characteristics. Draw before steroids, plasma exchange or immunosuppressants where possible.
    Result
  2. Area postrema criteriaSymptoms 48 hours or more, or less with a new area postrema lesion; other causes excluded.
    Result
  3. MRI of brain and spinal cordMandatory in the NEMOS workup. Orbital MRI in selected patients.
    Result
  4. Lumbar punctureOligoclonal bands, cell count and differential, protein, lactate, glucose.
    Result
  5. Serum MOG-IgG, cell-based assayAQP4-IgG negative patients who meet NMOSD criteria. Meeting MOGAD criteria replaces the NMOSD label, per NEMOS.
    Result
  6. Confirm or repeatSecond assay type for a low-titer ELISA positive or atypical picture. Retest seronegatives who relapse or before B-cell therapy.
    Result
  7. 2015 IPND criteriaAQP4-IgG positive: 1 core characteristic. Negative or unknown: 2 core characteristics plus MRI requirements. Exclude alternatives.
    Result

5Results the sources say do not rule it out

  • A negative AQP4-IgG drawn after steroids, plasma exchange or immunosuppressants.
  • A single negative AQP4-IgG. Later tests turned positive after years in some misdiagnosed patients.
  • A cord lesion shorter than 3 segments. Seen in 7% to 14% of first myelitis attacks.
  • MS-like white matter lesions on brain MRI. Up to 16% meet Barkhof MS criteria.
  • An unrevealing gastroscopy, small bowel X-ray or abdominal ultrasound in intractable vomiting.
  • A positive AQP4-IgG by ELISA alone in an atypical picture. Confirm by cell-based assay.

6Specialists the sources name

Diagnosis code: G36.0 Neuromyelitis optica [Devic]Codes patients often carry before diagnosis are listed in the online guide.
Full guide and sourcesEvery point here is sourced in the online guide, which also has a patient note to print.
Trial Friend, trialfriend.com/for-clinicians. Key sources: 2015 IPND diagnostic criteria; NEMOS 2023 recommendations, part I; NEMOS 2024 recommendations, part II; Shosha 2018 area postrema study; Apiwattanakul 2010 Mayo Clinic vomiting series; Iorio 2013 gastroenterology study; all 34 with links in the online guide. Checked November 11, 2026. A reference checklist for licensed clinicians that summarizes published sources. It is not a diagnostic tool, a score or a protocol, and it does not replace clinical judgment, local practice or the prescribing information. Not coding advice. Trial Friend never receives anything written or typed on this sheet.