Acute "idiopathic" peripheral facial palsy: clinical, serological, and cerebrospinal fluid findings and effects of corticosteroids

INTRODUCTION

The causes for peripheral facial palsy remain obscure in many patients. Evidence exists suggesting viruses, especially those belonging to the herpesvirus group, may be causative. This study was developed to evaluate this theory.

METHODS

One hundred forty-seven patients with acute peripheral facial palsy of primarily unknown origin were studied. All were examined within 1 week of onset. Subsequent follow-up was undertaken until the palsy had recovered or become static. Paried cerebral spinal fluid and serum samples were obtained for serological evaluation to detect herpes simplex, varicella zoster, cytomegalovirus, measles, mumps, rubella, tick-borne encephalitis, adenovirus, Epstein-Barr virus, and human immunodeficiency virus, as well as the antibodies to Borrelia burgdorferi.

RESULTS

Elevated antibiotic titers to Borrelia burgdorferi were observed in 11% of patients, whereas 9% of patients demonstrated elevated viral titers. Antibody pattern consistent with Epstein-Barr virus reactivation was present in 13%. A total of 67% were classified as idiopathic.

CONCLUSION

Patients with reactivated Epstein-Barr virus were characterized by having a higher incidence of auricular pain and displayed diabetes mellitus in a higher frequency than in other groups. In the Borrelia group, neck/back pain was more common. Healing was less favorable in the Borrelia group despite an equal rate of palsy at onset and adequate antibiotic treatment. Corticosteroid treatment used in 44% of the patients did not significantly improve the functional outcome.

Comparison of seven formulae and isoelectrofocusing for determination of intrathecally produced IgG in neurological diseases

Seven different formulae and agarose isoelectrofocusing (AIF) using immunolabelling for IgG were compared for their ability to discriminate between intrathecally produced IgG and transudated IgG in cerebrospinal fluid. All reference limits were set to a specificity of 97.5% (reference group, n = 211). The probability of a positive test (p+) was evaluated for 112 patients with multiple sclerosis (MS), 42 with meningitis, 114 with noninflammatory diseases affecting the central nervous system (CNS), 23 with Guillain-Barré syndrome, and 56 with various diseases not affecting the CNS. Agarose isoelectrofocusing had the best diagnostic sensitivity (93%) for MS, combined with a low p+ (0-19%) for other diseases. Among the formulae, the IgG extended index and Reiber's hyperbolic formula were equivalent, giving high (75-79%) diagnostic sensitivity for MS combined with low p+ (4-22%) for other diseases. All other formulae, although sensitive for MS, had a higher rate of false positive results.

Serum levels of lymphokines and soluble cellular receptors in primary Epstein-Barr virus infection and in patients with chronic fatigue syndrome

The immunopathology in primary Epstein-Barr virus (EBV) infections and in chronic fatigue syndrome was studied by examining serum levels of interleukins (IL) and of soluble T cell receptors in serum samples. Serum samples were from patients during and 6 months after primary EBV-induced infectious mononucleosis and from patients with chronic fatigue syndrome and serologic evidence of EBV reactivation. Markers for T lymphocyte activation (soluble IL-2 and CD8) and for monocyte activation (neopterin) were significantly elevated during acute infectious mononucleosis but not in patients with chronic fatigue syndrome. Interferon-alpha, IL-1 beta, and IL-6 levels were not significantly increased in any patient group but inferferon-gamma levels were significantly increased during the acute phase of infectious mononucleosis. The levels of IL-1 alpha were significantly higher than in controls both in patients with infectious mononucleosis and in those with chronic fatigue syndrome. In the latter, the lack of most markers for lymphocyte activation found in patients with infectious mononucleosis makes it less likely that EBV reactivation causes symptoms.

Acute peripheral facial palsy: CSF findings and etiology

CSF and serum were examined in acute and convalescence phase from 56 patients with acute idiopathic peripheral facial palsy. CSF protein analysis, viral and borrelia serology were performed. Borrelia infection was found in 9/56 cases and was often associated with inflammatory CSF findings. One patient each had serological evidence for a recent or ongoing infection with herpes simplex, varicella zoster, adeno, influenza B, echo and Epstein-Barr virus, but none had specific intrathecal antibody synthesis; 11 patients had a serological pattern compatible with a reactivated Epstein-Barr virus infection. Eleven patients displayed mononuclear CSF pleocytosis. Four of them had a borrelia infection. A disturbed blood-brain barrier was observed in 19 patients. Intrathecal immunoglobulin synthesis as indicated by elevated IgM-indices was found in 16 patients and by IgG indices in three. Nine patients had oligoclonal IgG bands in serum and CSF, three exclusively in CSF. It is concluded that patients with facial palsy often have inflammatory CSF findings, indicating a generalised central nervous system affection, and not only a mononeuritis. The importance of viral infections in the pathogenesis is still obscure. Borrelia is the most common infectious cause of facial palsy.

An improved formula for the judgement of intrathecally produced IgG in the presence of blood brain barrier damage

In order to develop a better formula for discrimination between transsudated and intrathecally produced IgG, we studied the relation between cerebrospinal fluid (CSF) IgG, serum IgG, CSF albumin, and serum albumin for patients with blood brain barrier (BBB) damage. From this study we derived a new formula, IgG extended index = (CSF IgG/serum IgG)/(CSF albumin/serum albumin). Applying this index on 152 patients with BBB damage, but not expected intrathecal IgG synthesis, yielded 14 patients (9.2%) with increased (greater than 1.24) IgG extended index. In comparison, 'conventional' IgG index was increased in 34 of the patients (22%). The diagnostic sensitivity for 68 patients with multiple sclerosis (MS), did not differ significantly between the two formulas (81 and 87%, respectively). A formula for the estimation of 24 hours IgG production was also developed, but this formula was not better than IgG index. Children (0.5-16 yr) had similar IgG patterns as adults.

Mononuclear cell types in cerebrospinal fluid and blood of patients with multiple sclerosis. Quantitation by immunoenzyme microassay with panel of monoclonal antibodies

Phenotypic distribution of mononuclear cells in cerebrospinal fluid (CSF) and peripheral blood from patients with multiple sclerosis (MS) and, for reference, patients with acute aseptic meningoencephalitis (AM), and in blood only from healthy controls, was studied with an immunoenzymatic microassay enabling analysis even in the presence of a normal CSF cell count. In MS, increased CD5+ (pan-T) cell proportion in CSF compared with blood was not reflected by changes of CD4+ or CD8+ cells, while in AM, an increase of CD4+ cells was registered. Therefore, a population of CD5+, CD4-, and CD8- cells may be anticipated to exist in CSF of patients with MS. Numbers of OKB7+, OKM1+, or HLA-DR+ cells did not distinguish between MS and AM. Proliferating cells expressing transferrin receptors (OKT9+ cells) were generally few or absent in CSF and not useful as a marker of disease activity in either MS or AM.

A new diagnostic approach to the patient with severe pneumonia

36 patients with severe community-acquired pneumonia, treated in an intensive care unit (ICU), were examined in a prospective study using a comprehensive diagnostic program to establish an early etiological diagnosis. The resulting prompt and adequate antimicrobial therapy may have decreased the number of fatal cases. Special emphasis was placed on the use of a method incorporating fiberoptic bronchoscopy, together with protected brush sampling and bronchial lavage. An etiological diagnosis was established in 81% (29/36) of the cases. This etiological diagnosis was established within 48-72 h in 53% (19/36) of the patients, S. pneumoniae being the most frequent agent found (12 patients). This information, however, was poorly utilized since in only 11/19 of these patients was the antimicrobial therapy changed from a broad-spectrum antibiotic to a more specific narrow spectrum agent. The overall mortality rate was 22% (8/36). 7/8 patients who died had compromising factors. Most deaths in community-acquired pneumonia are still associated with pneumococcal infection. We conclude that fiberoptic bronchoscopy with brush samples via a plugged double lumen catheter provides the least misleading information concerning the etiological agent in pneumonia; sampling should be done as soon as possible after admission to the hospital, ideally before the need for ICU treatment; factors other than prompt antimicrobial therapy may influence the outcome of severe community-acquired pneumonia.

Leukocyte types in cerebrospinal fluid and peripheral blood enumerated immunoenzymatically in aseptic meningitis and the Guillain-Barré syndrome

To study celltype distribution simultaneously in peripheral blood (PB) and cerebrospinal fluid (CSF) from patients with aseptic meningitis (AM) (n = 14) and Guillain-Barré syndrome (GBS) (n = 9) we used an immunoenzymatic method that enabled the use of several monoclonal antibodies, also in CSF samples with normal cellcounts. In both patient groups a different cell-distribution in CSF compared to PB was found with regard to pan T cells (CD5+/anti-Leu1+), T cell subpopulations (CD4+/anti-Leu3+, CD8+/anti-Leu2+), B cells (OKB2+, OKB7+), monocytes/macrophages (CD11+/OKM1+) and HLA/DR expressing cells, whereas the distribution of HLA/DC+ cells was similar in CSF and PB. Thus, the CSF cell distribution does not reflect the distribution in PB. The proportion of T cells was higher and the proportion of B-cells was lower in CSF than in PB in both patient groups, which is a finding similar to that in patients with multiple sclerosis. The OKT9 marker, labelling proliferating cells expressing the transferrin receptor, was not useful as marker of local proliferation.

Mumps with laboratory signs of subclinical pancreatitis may cause a disturbed beta-cell function

Mumps epidemics are followed by sporadic cases of insulin dependent diabetes mellitus (IDDM). We have studied beta-cell function in 11 subjects who had had a mumps infection. They had no clinical pancreatitis but were selected as they had abnormal pancreas iso-amylase values and/or glucosuria during the mumps virus infection. At the follow-up some years later the subjects were healthy. A few HbA1-values were noted in the upper part of the normal range. Total serum insulin values were normal, but the C-peptide values were low at first follow-up 1-3 years after infection in all but two patients. These values increased in 4/7 patients during the follow-up period but were subnormal in five subjects still 3-6 years after the infection. All five patients had HLA-DR 3 and/or 4. In 7 out of 11 patients islet cell surface antibodies could be demonstrated. Our results indicate that subclinical mumps pancreatitis may initiate a reaction towards the beta-cells recognized as subnormal C-peptide levels several years later in certain patients. This might contribute to manifest IDDM many years after infection.

Comparison of concentration of orosomucoid in serum and cerebrospinal fluid in different neurological diseases

We compared orosomucoid levels in cerebrospinal fluid (CSF) in patients with aseptic meningitis, multiple sclerosis, ischemic and hemorrhagic stroke, CNS-affecting leukemia/lymphoma, and CNS-tumor with the levels in a reference group not having neurologic diseases. Because of possible blood brain barrier damage, we corrected for orosomucoid derived from serum by using the orosomucoid index, i.e. (CSF/serum orosomucoid)/(CSF/serum albumin). Elevated CSF orosomucoid was found in several diseases. In no case, however, was there any evidence of intrathecal synthesis of the protein. We concluded that CSF orosomucoid determination, when used as the only, measure, is of limited clinical value.

Immunoglobulin abnormalities in the cerebrospinal fluid during bacterial meningitis

11 patients with bacterial meningitis, examined during the course of the disease for immunoglobulin (Ig) abnormalities in the cerebrospinal fluid (CSF), all had an increased CSF IgM index equal to (CSF/serum IgM):(CSF/serum albumin), indicating intrathecal IgM production. Seven patients had a slightly increased CSF IgG index, and 7 a slightly increased IgA index. Six of the 11 patients had an increased IgM index in the presence of normal indices for IgG and IgA. Follow-up revealed the return of these values to normal. Four patients had identical oligoclonal IgG bands in the CSF and serum, probably representing a systemic immune response, but in only one case were oligoclonal bands suggestive of intrathecal IgG production found. No oligoclonal IgA response was demonstrable in the 4 patients examined. Antigen-immunofixation or antigen-absorption studies revealed evidence of a specific, intrathecal IgG antibody response in only 2 patients, while a search for IgG antibodies against aetiologically unrelated bacterial and viral antigens was negative. With the exception of IgM production, therefore, a humoral intrathecal immune response is less common in bacterial than in aseptic meningitis.

Production of specific antibodies by cerebrospinal fluid lymphocytes in patients with herpes zoster, mumps meningitis and herpes simplex virus encephalitis

We applied a new method consisting of short-term culture (18 h) of lymphocytes from cerebrospinal fluid (CSF-L) and peripheral blood (PBL) in viral antigen-coated ELISA plates and subsequent measurement of IgG and IgM antibodies bound to antigen. Utilizing mumps virus, herpes simplex virus (HSV), varicella zoster virus (VZV), and measles virus as antigens, we demonstrated production by CSF-L of antibodies against the aetiological agent only in all patients with mumps meningitis and HSV encephalitis and also in all patients with herpes zoster without central nervous system (CNS) symptoms. This might be considered as direct evidence that specific antibodies are produced within the CNS in inflammatory nervous system diseases. CSF-L usually produced higher amounts of antibodies than the corresponding number of PBL. In comparison with concentrations of free antibodies determined in parallel, our method had higher specificity and sensitivity and gave more precise information about the antibody response in infections of the nervous system.

Viral IgM and IgG antibody synthesis within the central nervous system in mumps meningitis

With the use of enzyme-linked immunosorbent assay (ELISA) for demonstration of specific viral antibodies in 21 patients with mumps meningitis (MM), 19 (91%) displayed evidence for synthesis within the central nervous system (CNS) of IgG antibodies and 11 (52%) of IgM antibodies. Only one MM patient did not show local antibody production, but he had high mumps IgM titers in serum. Elevated IgG and IgM indices reflecting local IgG and IgM production, were found in 4 (19%) and 17 (81%) of the patients, respectively, and frequently did not coincide with local synthesis of specific antibodies. None of 21 control patients with acute aseptic meningitis of other etiology showed evidence for a local antibody response against mumps. In one of the MM patients, local production of measles IgM antibodies was demonstrated, reflecting an IgM response within the CNS against an antigen unrelated to the disease. This study concludes that in less serious CNS infections, such as MM, highly sensitive methods as ELISA are needed to demonstrate intrathecal specific viral immune response.

Cerebrospinal fluid lymphocytes from patients with multiple sclerosis do not increase immunoglobulin or measles antibody production after stimulation with pokeweed mitogen

Cerebrospinal fluid lymphocytes (CSF-L) and peripheral blood lymphocytes (PBL) from patients with multiple sclerosis (MS) and acute aseptic meningoencephalitis (AM) were cultured without and in the presence of pokeweed mitogen (PWM), a polyclonal B cell activator. IgG, IgA and IgM as well as measles IgG antibody production was measured in 7-day-culture supernatants by enzyme-linked immunosorbent assay. MS CSF-L did not respond with increased Ig production after PWM stimulation, in contrast to AM CSF-L which responded to PWM with a modest increase of production of all 3 Ig classes, especially IgG. PBL responded to PWM with a pronounced production of IgG, IgA and especially IgM, showing no difference between MS, AM and healthy controls. CSF-L from only 1 of 7 patients with MS showed increased measles IgG antibody production after PWM stimulation. The poor response of MS CSF-L might be due to maximal activation of B lymphocytes in vivo, thereby limiting further Ig production after stimulation in vitro.

Determination of species- and laboratory-related interpretive breakpoints for doxycycline susceptibility testing using single-strain regression analysis

Single-strain Regression Analysis (SRA) was performed for doxycycline on a total of 68 bacterial strains representing 16 different species. Species- and laboratory-related zone diameter breakpoints were determined and compared with histograms of zone diameter values obtained from 942 routine susceptibility tests. Calculated breakpoints were similar within individual species. When considering the homogeneity of susceptibility groups within bacterial species, the calculated breakpoints gave rise to relatively few interpretive errors. In contrast, general breakpoints for doxycycline as recommended by the Swedish Reference Group (SRG) (R less than = 20 mm and S greater than = 26 mm) would give rise to a high proportion of false interpretations in the present laboratory. Fifty-three per cent of H.influenzae strains would have been assigned to the wrong susceptibility group. For E.coli and K.pneumoniae, 22 and 35 per cent, respectively, would have been erroneously categorized using SRG breakpoints. E.cloacae and E.aerogenes would have been assigned another category in 39 and 50 per cent, respectively. The procedure for setting species-specific and laboratory-related interpretive breakpoints is described. Determination of species- and laboratory-related interpretive breakpoints using SRA provides a new approach towards improved accuracy of disc-diffusion susceptibility testing.

Reference values for CSF-IgM, CSF-IgM/S-IgM ratio and IgM index, and its application to patients with multiple sclerosis and aseptic meningoencephalitis

Immunoglobulin M (IgM) concentrations were determined in cerebrospinal fluid (CSF) and serum (S) by enzyme-linked immunosorbent assay (ELISA). In 52 reference subjects, the upper reference limit was 0.46 mg/l for CSF-IgM, 0.32 X 10(-3) for CSF-IgM/S-IgM ratio, and 0.061 for IgM index equal to CSF-IgM X S-albumin/S-IgM X CSF-albumin ratio. No correlation to age over 15-85 years was found for any of these variables. Among 22 patients with aseptic meningoencephalitis (AM) elevated values of CSF-IgM were found in 68%, CSF-IgM/S-IgM ratio in 73%, and IgM index in 73%. The corresponding values among 35 patients with multiple sclerosis (MS) were 66%, 60% and 63%. The differences in diagnostic sensitivities for the three IgM variables were not significant. Eleven of 16 AM patients and two of 22 with MS had elevated IgM index in the presence of normal IgG and IgA indices. Determination of IgM index should therefore be performed in suspected inflammatory nervous system disorders.

Synthesis of the complement factors C3 and C4 within the central nervous system over the course of aseptic meningitis

The concentrations of complement factors C3 and C4 were quantified by single radial immunodiffusion in unconcentrated cerebrospinal fluid (CSF) and in serum from 38 patients up to 2 months after onset of acute aseptic meningitigs (AM). Elevated absolute concentrations were found in CSF in 26 and 35 patients, respectively, and in serum in 8 and 31, respectively. Elevation of the CSF C3 index, equal to (CSF/serum C3):(CSF/serum albumin), and of the corresponding CSF C4 index were found in 16 and 7 patients, respectively, as evidence of intrathecal synthesis. Only minor differences of the frequencies of elevated CSF C3 and C4 indices were encountered over the course of AM up to 2 months after onset. The occurrence of intrathecal C3 and C4 synthesis in AM is proposed as reflecting activation of hitherto unknown significance within the central nervous system.

Immunoglobulin-producing cells in blood and cerebrospinal fluid during the course of aseptic meningoencephalitis

The protein A plaque assay was used to quantitate the number of IgG-, IgA-, and IgM-producing cells per 20 X 10(3) lymphocytes in cerebrospinal fluid (CSF) and peripheral blood (PB) from 23 patients with aseptic meningoencephalitis (AM) in the acute stage 1-10 days after onset (group I) and during late convalescence after 19-38 days (group II) and in PB from healthy controls. In the acute stage, IgG- and IgM-producing cells were found with significantly higher frequency in both CSF and PB than in the late convalescence. In both patient groups there were more Ig-producing cells in PB than in CSF. The predominant Ig class in PB of AM patients was IgA, just as in healthy individuals. In CSF, IgA- and IgG-producing cells predominated at similar frequencies. In the group I patients, there were positive correlations between numbers of Ig-producing cells of each class and the corresponding CSF Ig index, an indicator of intrathecal Ig synthesis. Since high numbers of Ig-producing cells could be found in CSF that was otherwise normal, enumeration of Ig-producing cells is considered a more sensitive indicator of the immune response intrathecally than measurement of free Igs.