case_images: PMC10902669_01
case_images: Timeline of disease disability course and different treatment regimes. The x-axis indicates the number of days after admission. The left y-axis indicates ALT (IU/L) and AST (IU/L). The right y-axis also indicated EDSS score. ALT: normal values < 40 IU/L ml; AST: normal values < 35 IU/L; EDSS is used to quantify the level of disability in NMOSD, ranging from 0 to 10, with higher scores representing increasing levels of disability; IVIG: 0.4 g/kg intravenous immunoglobulins daily for 5 days; IVMP, intravenous methylprednisolone 1000 mg for 5 consecutive days, followed by oral prednisone (1 mg/kg) with a weekly reduction of 5 mg. Throughout the entire immunotherapy process, ALT and AST showed some fluctuations without significant elevation. There was no clinical improvement after receiving IVMP and IVIG, and the EDSS score worsened to 9 on day 15 from admission. Ofatumumab was subcutaneously injection on days 39, 46, 53 (20 mg per dose) from admission; inebilizumab was intravenously infusion on days 83, 90 (300 mg per dose) from admission. After receiving ofatumumab and inebilizumab treatments, there was a gradual improvement in symptoms, and the EDSS score changed from 9 to 3. ALT, aspartate aminotransferase; AST, alanine aminotransferase; IVMP, intravenous methylprednisolone; IVIG, intravenous immunoglobulin; OP, oral prednisone; OFA, Ofatumumab; INE, inebilizumab; EDSS, Expanded Disability Status Scale.
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case_images: The initial Expanded Disability Status Scale (EDSS) score was 6.5 points ( Figure 1 ). The test for anti-AQP4 antibodies was positive in both the serum (titer, 1:10) and CSF (titer, 1:3.2) with a commercial kit (Euroimmun, Germany) ( Supplementary Figure 1 ). During the 150-day follow-up period, the timeline of disease disability, different treatment regimens, and changes in liver function were depicted in  Figure 1 . After the administration of ofatumumab, the patient's symptoms gradually improved ( Figure 1 ), and no HBVr was observed. The patient's symptoms also improved, reflected in the EDSS score, which decreased from 9 to 3 ( Figure 1 ).
case_images: Sequence reads mapped to HBV in CSF from NGS results. (A) Sequence reads of HBV DNA in CSF with a total coverage of 69.18% and an average depth of 6.22 X; (B) Sequence reads of HBV RNA in CSF with a total coverage of 1.57% and an average depth of 1.00 X. HBV, hepatitis B virus; CSF, cerebrospinal fluid; NGS, next generation sequencing.
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case_images: The sequencing was performed using the Illumina NextSeq 550 sequencing platform (Illumina, San Diego, USA) and a SE75bp sequencing strategy ( Figure 2 ).
case_images: Brain MRI. Lesions (arrowed) on brain MRI images before (A-E) and after (F-J) antiviral and immunotherapy showing obviously manifested shrinkage after treatment. (A) T2-weighted showed medulla oblongata lesion. Lesion area: 2.4 cm2; (B) T2-weighted showed dorsal aspect of the brainstem and left cerebellar peduncle lesions. Lesion area: 3.3 cm2; (C) T2-weighted showed dorsal aspect of the brainstem and left cerebellar peduncle lesions. Lesion area: 1.8cm2;
  (D) No significant enhancement before treatment; (E) Diffusion-weighted MRI (DWI) showed mild limited diffusion. Lesion area: 1.7 cm2; (F) T2-weighted showed a reduction in the area of medullary lesions, with an area of 1.0 cm2; (G) T2-weighted showed a reduction in the area of brainstem and left cerebellar peduncle lesions, with an area of 2.0 cm2; (H) T2-weighted showed a reduction in the area of brainstem and left cerebellar peduncle lesions, with an area of 0.7 cm2; (I) No significant enhancement after treatment; (J) Sagittal view showed medulla oblongata lesion.
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case_images: Brain MRI using T2-weighted sequences showed high signals in the brain stem, medulla oblongata, and left middle cerebellar peduncle with mild restricted-diffusion, but no significant enhancement ( Figures 3A-E ). By day 90, significant progress was evident, with brain MRI revealing reduced lesions compared to the previous scan ( Figures 3F-J ) and the HBV DNA in serum dropping to 1.32x105 IU/mL.