Cytomegalovirus as a frequent cause of Guillain-Barré syndrome

In 10 patients with Guillain-Barré syndrome a preceeding cytomegalovirus infection could be demonstrated by virus-specific IgM antibodies that were present in high titers in 9 of the 10 patients in the first serum specimen. The IgM antibodies to cytomegalovirus were detected by a sensitive "double" indirect immunofluorescence technique. In most of our cases (8 of 10) the complement-fixing antibody titers had already reached high levels on admission into a hospital, and significant titer changes were not observed. Cytomegalovirus was isolated from the urine of five patients.

[Guillain Barré- polyneuroradiculitis and Fisher-syndrome in cytomegalovirus infections (author's transl)]

In seven patients suffering from polyneuroradiculitis of the Guillain-Barré type and one case of Fisher syndrome, a cytomegalovirus infection was found. The elevation of the virus-specific IgM-antibodies was confirmed in all cases. The clinical course was severe and acute with respiratory disturbances, but complete remission occurred within 1-4 months. The complement fixing antibodies were highest during the first week of illness, so that further elevations could not be demonstrated, therefore making the IgM-antibody method of special importance. The role of cytomegalovirus infections in polyneuroradiculitis is also discussed.

Circulating immune complexes in multiple sclerosis and other neurological diseases

Circulating immune complexes were detected in 49% of sera from patients with multiple sclerosis, 45% of monosymptomatic optic neuritis, 45% of Guillain-Barré syndrome, and 15% of normal sera studied. The frequency of immune complexes in multiple-sclerosis sera was not correlated with the clinical status of the patients. Results with serial blood-samples were variable.

[Recurrent polyneuropathy with a 19-year course, associated with a benign IgG monoclonal gammapathy]

A case of recurrent polyradiculoneuritis in a 54-year-old man is described. It is exceptional because of its lengthy development over a period of 19 years and by its association with a paraprotein of the IgE type without anyother anomal. Corticotherapy had a favourable effect on the clinical symptoms but did not affect the amount of monoclonal immunoglobulin in the serum. The nosological position of this neuropathy and the type of gammapathy are discussed. An immune mechanism seems likely, but no proof of a link between the neuropathy and the gammapathy could be found.

Antibodies to Epstein-Barr virus and cytomegalovirus in Guillain-Barre syndrome

Twenty-three patients with Guillain-Barré syndrome (GBS) were investigated for serum antibody titres against Epstein-Barr virus capsid antigen (EBV-VCA), cytomegalovirus (CMV) and herpes simplex virus type 1 (HSV1). The geometric mean EBV-VCA titre was 45 in GBS, compared with 15-22 in healthy adults and 60 in sarcoidosis. Nine of the 15 GBS patients (60%) from whom multiple serum specimens were available, displayed a four-fold variation in antibody titre to EBV-VCA during the course of their disease. The geometric mean titres against CMV and HSV were also slightly higher in GBS compared with controls, but no titre variations were observed. Serial samples of both serum and cerebrospinal fluid (CSF) were available from 2 patients. Serum antibody titres against EBV were significantly higher in both during the initial phase of the disease. Serum antibody titres against CMV were also significantly elevated in 1 patient, but not until the second month after onset. The CSF antibody titres against EBV were higher in the beginning of the disease compared with the values during convalescence, but the titres observed were low. No measurable CSF antibody titres against CMV were found. The observation of varying serum antibody titres against EBV during the course of GBS can be interpreted as primary infections or as manifestations of reactivated latent virus infections. Further studies of the pathogenetic significance of this for the aetiology of the disease are warranted.

Lymphocyte transformation studies in Mycoplasma pneumoniae infections

The in vitro transformation of lymphocytes stimulated by a Mycoplasma pneumoniae preparation was measured by the uptake of 14C-thymidine. The lymphocytes from five patients with M.pneumoniae pneumonia showed a high degree of responsiveness when they were compared to the lymphocytes taken from eleven healthy control subjects who lacked M.pneumoniae antibodies. Another four patients with an acute affection of the central nervous system and serological evidence of an actual or recent M.pneumoniae infection had a lymphocyte response within the same range as that of the controls. The transformation of lymphocytes was studied at intervals for seven months after the onset of the illness in one of the patients with pneumonia. These studies showed an increasing response to a small dose of mycoplasma antigen. Lymphocyte transformation induced by other microbial antigens was studied in three pneumonia patients during and after convalescence. The first responses were low and increased more steeply than the response to M.pneumoniae. The later responses to the mycoplasmal and to the other microbial antigens increased in parallel. The usefulness of incorporating other microbial antigens in the evaluation of the patient's immune response to a relevant antigen in this type of experiment is discussed.

Optic neuritis in the Landry-Guillain-Barré-Strohl syndrome

A patient with typical Landry-Guillain-Barré-Strohl syndrome (LG-BS) developed bilateral optic neuritis. Laboratory studies showed hypersensitivity to both central and peripheral nervous tissue myelin. The occurrence of optic neuritis is presumably due to autohypersensitivity to central nervous tissue myelin. The initial lesions of the LG-BS syndrome in the peripheral nerves might have liberated sequestered antigens that cross-reacted with central nervous system myelin.

Cell-mediated immunity to neural antigens in idiopathic polyneuritis and myeloradiculitis. Clinical-immunologic classification of several autoimmune demyelinating disorders

Patients with peripheral nervous system disorders were tested for the presence of cellular hypersensitivity to peripheral and central nervous system antigens by means of the in vitro lymphocyte transformation technique. Lymphocytes sensitized to the neuritogenic peripheral nervous system P1L basic protein were found in pure polyradiculitis of the Guillain-Barré syndrome type. Lymphocytes from patients with myeloradiculitis underwent transformation by peripheral P2 basic protein and by central nervous system basic encephalitogenic protein. In cases of chronic relapsing polyneuropathy response was shown to the central nervous system basic encephalitogen and to both of the peripheral nerve basic proteins. Lymphocytes from patients with other neurologic conditions showed no response to any oth these antigens. These findings suggest that cell mediated immunity to specific basic proteins of the myelin plays a rolw in the pathogenesis of the above-mentioned demyelinating disorders and may lead to a new approach in their classification and diagnosis.

Neurologic complications with elevated antibody titer after acute hemorrhagic conjunctivitis

Nine patients with polyradiculomyeloneuropathy after acute hemorrhagic conjunctivitis (AHC) infection were studied serologically. All except one patient had neutralization titers larger than or equal to 1:16 against the prototype J670/71 strain of AHC virus in at least one of their serum samples. The development of a significant fourfold rise in antibody titer against AHC virus occurred in one of the patients who developed neurologic complications five days after the onset of AHC infection.

[Pathogenesis of neural lesions in Marek's disease. I. Allergic skin reaction against myelin of the peripheral nerves (author's transl)]

23 chickens affected with Marek's disease were tested by the allergic skin reaction for delayed hypersensitivity against myelin and myelin preparations of peripheral nerves. 19 animals proofed to be positive in the skin test, yet there was no correlation with the intensity of the nerve affections. 4 animals with severe mononuclear neural infiltrations didn't show any allergic skin reaction. It could be demonstrated that in Marek's disease lymphocytes are sensitized against components of the peripheral myelin. Thereafter, Marek's disease stands in analogy to the Guillain-Barré syndrome of man, as well as to experimental allergic neuritis.

Cellular immune response to peripheral nerve basic protein in idiopathic facial paralysis (Bell's palsy)

Lymphocytes from patients with Bell's palsy were shown to undergo significant stimulation when cultured in vitro in the presence of a purely neuritogenic basic protein (P1L) isolated from human peripheral nerve myelin. No sensitization was observed to other neural antigens, namely, another periperal nerve myelin basic protein (P2) and the central nerve myelin basic encephalitogenic protein (BE). A similar pattern of response was also demonstrated in patients with Guillain-Barré syndrome (GBS). Lymphocytes from patients suffering from other neuropathies or other diseases involving the face showed no response to any of these antigens. The specific in vitro response to P1L protein in Bell's palsy may suggest that an in vivo sensitization of lymphocytes to such self protein occurs in this condition, and that cell-mediated, probably post-infectious, autoimmune mechanisms may be an important factor in the pathogenesis of the paralysis. Thus, Bell's palsy is immunologically similar to GBS, or may even represent a mononeuritic variant of GBS. In view of these findings the administration of steroids to patients with Bell's palsy seems logical on the basis of their immunosuppressive action.

Cellular hypersensitization to peripheral nervous antigens in the Guillain-Barré syndrome

The macrophage migration inhibition factor assay was used as a specific measure of cellular hypersensitivity to peripheral nervous system antigen in a large group of Guillain-Barre patients and control subjects. Lymphocytes from 34 patients with Guillain-Barre syndrome, 33 with other peripheral nervous system disease, and 33 normal controls were assayed for production of macrophage migration inhibition factor. A mean of 101 +/- 7.2 was obtained in the control group, 70 +/- 16.3 in the Guillain-Barre syndrome group, and 96 +/- 11.3 in those with other peripheral nervous system disease. Twenty-six of the 34 patients with Guillain-Barre syndrome, two patients with myeloradiculitis, and two with Bell's palsy gave significant values. These results support the hypothesis that cellular hypersensitization to peripheral nervous system antigens is a pathogenetic factor in Guillain-Barre syndrome.

Demonstration of oligoclonal immunoglobulin G IN Guillain-Barré syndrome

Elevated concentrations in CSF of the immunoglobulins G, A, and M, when expressed as a percentage of the total protein concentration of CSF, were demonstrated during the initial phase of the course of the disease in a patient with Guillain-Barre syndrome (GBS). A slight elevation of the relative concentrations of IgG and IGM in CSF were also registered later in the course of the disease, at the time when the patient's neurological symptoms were in regression. Multiple discrete IgG bands were demonstrated by agarose electrophoresis in serum and in CSF during the first 2 weeks after onset of the neurological symptoms, and also after week 2 and still during week 12 after onset. The finding of transient oligoclonal IgG in a parient with GBS may suggest stimulation with e.g. viral antigen.

[On the behaviour of the main immunoglobulin fractions in the CSF in the course of inflammatory conditions involving the CNS (AUTHOR'S TRANSL)]

Variations of the main immunoglobulin fractions in CSF were studied in 79 children with various inflammatory processes of CNS (purulent and viral meningitis, post-infectious meningoencephalitis, polyradiculoneuritis, etc). This study was extended to a group of non-inflammatory neurological diseases. Increased values of CSF immunoglobulins (especially IgG and IgA) were found in the group of purulent meningitis and in the group of post-infectious meningoencephalitis. IgM was detected in very few cases. Generally, a correlation was observed between highest concentrations of CSF immunoglobulins and degree of meningeal inflammatory response, even if this was a component of other neurological diseases. It is suggested that the rise of CSF IgG and IgA may depend upon the CSF-blood barrier damage, as it occurs in most inflammatory diseases studied. On the contrary, a production "in situ" of CNS could explain the presence of cerebrospinal IgM.

Cellular hypersensitivity to basic myelin (P2) protein in the Guillain-Barré syndrome

Lymphocytes of 29 subjects were assayed for MIF production in response to P2 peripheral nerve protein, crude human peripheral nerve and human central nervous system Al basic myelin protein. Seven were performed in normal control subjects, 12 in Guillain-Barre patients (GB), 5 with other polyneuropathies and 5 in patients with multiple sclerosis (MS). Only GB patients with acute illness produced MIF in response to neuritogenic P2 protein and crude human nerve. Two MS patients in the acute phase of an exacerbation and one GB patient produced MIF in Response to Al protein. The results of this study demonstrate cellular hypersensitivity to a neuritogenic consituent in peripheral nervous tissue and support the concept that this may be important in the pathogenesis of GB.

[IgM immunoglobulin in cerebrospinal fluid in cases of multiple sclerosis (preliminary report)]

In cases of multiple sclerosis, central nervous system syphilis and other neurological diseases the IgM was determined in the cerebrospinal fluid by means of radial diffusion. The control group comprised patients with neurosis. It was found that IgM determinations must be done in concentrated fluid when this method is used. Raised total and percent level of IgM in the cerebrospinal fluid was observed in 8 out of 29 cases of multiple sclerosis in the acute phase of the disease.

Guillan-Barré syndrome in heroin addiction

In two cases of Guillain-Barré syndrome (acute polyneuritis) as a complication of narcotic abuse, the onset of paralysis began approximately 4 and 12 hours after self-administration of opiates intravenously. Bulbar and respiratory paralysis developed in one patient and required prolonged ventilation therapy; the other patient had peripheral muscular and unilateral facial weakness, with notable pleocytosis was present in both.

[A case of Guillain-Barré syndrome following cholera vaccination (author's transl)]

A 45-year-old woman developed bilateral ascending flaccid paralysis after cholera vaccination, 15 days after the first and 1 day after the second injection. The clinical course resulted in nearly complete paralysis of the lower limbs, paresis of the upper limbs and partial involvement of the cranial nerves. There was only slight sensory loss. The CSF revealed no pleocytosis and a protein level of 206 mg/100 ml. Recovery began 2 weeks later and was almost complete after 2 months. Immunological investigations revealed no remarkable changes.

Antimyelin antibodies in neurologic diseases. Immunofluorescent demonstration

Antimyelin binding activity was determined in patients with multiple sclerosis, amyotrophic lateral sclerosis, other neurologic diseases, and normals. There was an increase in the group mean titer of antimyelin antibodies in patients with multiple sclerosis (MS) in acute exacerbation, amyotrophic lateral sclerosis (ALS) and Guillain-Barré syndrome. A lesser degree of binding was found in normals of all ages. There was an increase in the incidence of antimyelin antibodies in the IgM class in patients with ALS and MS. The interaction between human immunoglobulins and myelin seems to be immunologically specific and has the nature of an antigen-antibody reaction.