A downward spiral undone: Jon Bratsch
Jon Bratsch had accepted that he was going to die. Barely conscious, breathing through a ventilator, and paralyzed in the intensive care unit, he could not see a way through the destructive illness that had taken so much from him.
Just three weeks earlier, Jon had felt fine. A happily married father of two grown girls, known throughout his hometown as a hard-working mechanic, Jon spent weekends riding his Harley-Davidson with his wife, Kris, seated behind him. To Kris and their daughters, it seemed impossible that Jon, a powerhouse whose strength was as much a tool of his trade as the equipment in his garage, could have fallen so gravely ill.
“I was taking care of my parents, taking care of this shop and my family, and then all of the sudden I couldn’t take care of myself,” Jon says. “That was kind of a rude awakening, you know?”
What knocked Jon down in late summer 2015 was his own immune system. Testing at Mayo Clinic Laboratories revealed that Jon’s immune cells, triggered by a cause not well understood, laid siege to a particular protein, called myelin oligodendrocyte glycoprotein (MOG), found on the surface of oligodendrocytes — a type of brain cell that helps make the myelin coating of nerve cells.
“When those cells get damaged, then the insulation is removed and patients have neurologic symptoms,” explains autoimmune neurologist Eoin Flanagan, M.B., B.Ch., a member of Jon’s care team and a Mayo Clinic Laboratories consultant who specializes in autoimmune neurologic conditions.
In Jon’s case, the damage was acute. “It’s as sick as a neurology patient can get,” says Dr. Flanagan. Dr. Flanagan’s laboratory colleague and mentor, Sean Pittock, M.D., led the development testing at Mayo Clinic Laboratories to detect the antibodies to MOG (Test ID: MOGFS) that confirmed Jon’s illness. “Having that MOG antibody result was really useful, as it helped guide our treatment to dampen down the inflammation and accelerate his recovery. We could now put a name to his illness and could tell the family what the future was likely to hold.”
The discovery of MOG antibodies put a hard stop to the rapid downward spiral that Jon was sure would be his ruin. And while his return to health was slow, the road forward was just as remarkable as his decline.
“This is a very powerful example of how the tests developed in the Mayo Clinic Neuroimmunology Laboratory can really make a difference to patients,” Dr. Flanagan says.
While Jon might never remember some parts of his medical journey — he fell into an eight-day coma just after arriving at Mayo Clinic Hospital in Rochester — the events leading up to his decline remain vivid in both his and Kris’ memories.
It was a Sunday morning at the end of the summer when Jon woke with a painful headache. It was unusual for Jon to develop headaches, and even more unusual that the pain progressively worsened over the course of a week. Eventually, the pain became so intense it forced Jon to leave work early and seek care at a medical center close to his home in Gaylord, Minnesota. There, he received pain medication, but it was largely ineffective.
A few days later he returned to the small hospital, where he was admitted and diagnosed with viral meningitis. He received antiviral treatment and more pain medication, but he became weak and confused. During the stay, Jon began losing feeling in his legs. Realizing Jon’s condition was worsening, Kris insisted his care be transferred to the larger medical center in nearby Mankato.
At Mayo Clinic Health System in Mankato, Jon deteriorated further. He lost all feeling in his legs and lower torso. Moving his arms became a challenge. He grew more confused. He underwent an MRI, but the results were inconclusive. Jon’s physicians reached out to their colleagues at Mayo Clinic in Rochester to arrange a transfer. During the 90-minute ambulance ride, Jon experienced breathing difficulties, and upon arrival was admitted to the Neurosciences Intensive Care Unit (ICU), where he was placed on a ventilator.
The device made breathing easier, however, it did nothing to improve Jon’s worsening symptoms. Within two days, he slipped into a coma.
While comatose and unresponsive, Jon underwent several more MRI scans. These showed spinal cord abnormalities and changes in the white matter of his brain. This prompted the leader of Jon’s ICU team, Sara Hocker, M.D., to consult with Dr. Flanagan.
“When I came to see him in the ICU, he was very sick,” Dr. Flanagan says. “He was weak in his arms and legs and severely confused, unable to follow commands.”
Based on the MRI results, as well as an analysis of Jon’s spinal fluid, which showed an overabundance of inflammatory cells, the neurology team believed Jon’s illness could be demyelinating with an autoimmune cause.
“We weren’t really sure of the exact diagnosis and, given how sick he was, we went ahead and proceeded with a brain biopsy,” Dr. Flanagan says. “It came back showing a type of inflammation that we call acute disseminated encephalomyelitis (ADEM).”
While the brain biopsy gave Jon a diagnosis, it didn’t explain what was causing the inflammation. Dr. Flanagan requested Jon’s blood be evaluated for MOG antibodies with a test that had been developed at Mayo Clinic Laboratories. At that time, in 2015, the test was only performed on a research basis. In 2018 it was implemented at Mayo Clinic Laboratories as a clinically available blood test.
“This MOG antibody came back extremely high and confirmed the diagnosis of MOG antibody-associated disease,” Dr. Flanagan says. “We knew what Mr. Bratsch had, and we knew how to treat it.”
The first treatment Jon received was high-dose intravenous steroids, which reigned in the inflammatory process in his brain. Next, several rounds of plasmapheresis, or plasma exchange, were administered. During this process, Jon’s blood was removed from his body and spun in a centrifuge. That caused all his antibodies, including the MOG antibodies, to separate from the blood cells. Once clear of the antibodies, the blood was returned to his body. Jon underwent seven rounds of plasmapheresis before his care team was satisfied that enough antibodies had been removed from his blood to have an impact.
“He began to improve with this combination of treatments,” Dr. Flanagan says. “He was able to come off the breathing machine. He started to regain some strength in his arms and legs, and he started to come back to us. He began to follow some commands.”
Jon’s improvement prompted his neurology team to move him to inpatient rehabilitation, where he stayed for 30 days. During that time, he slowly built back his strength and regained the ability to walk and move independently. In early October 2015, Jon was released from the hospital, and Kris brought him home.
“The really great thing was the next time I saw Mr. Bratsch in the clinic three months later, he was almost completely back to normal. He walked into the office and was able to engage fluidly in conversation,” Dr. Flanagan says.
“It was just amazing to see him recover so well. This shows the potential to reverse these autoimmune neurologic conditions.”
Following his hospitalization, Jon developed eye pain. An MRI scan and eye exam showed that he had developed eye inflammation related to MOG antibodies, which were affecting his optic nerves. The attack prompted Dr. Flanagan to consult with neuro-ophthalmologist John Chen, M.D., Ph.D. Together they devised a plan to treat the inflammation with oral medications. The medications dampened the immune system and prevented any further deterioration.
“Throughout this entire journey, from the bedside to the laboratory, this has been a Mayo Clinic team approach,” Dr. Flanagan says.
In the years since his life-threatening event, Jon has watched his daughters marry, welcomed grandchildren into his fold, and taken many motorcycle rides. He’s become more accepting of his circumstance and approaches life with an optimistic outlook.
“I’m still not 100%, maybe 90%, 85%. I don’t think I ever will be 100% because I’m too old; I’m 52 now,” Jon says. “I was 47 when this happened. I never thought I would see 48, so it’s all good. I got another chance.”