Clinical correlation with anti-peripheral-nerve myelin antibodies in Guillain-Barré syndrome

Incremental response to repetitive stimulation in Guillain-Barré syndrome

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Antibodies to acidic glycolipids in Guillain-Barré syndrome and chronic inflammatory demyelinating polyneuropathy

Using an enzyme-linked immunosorbent assay and a thin-layer chromatography-immunostaining procedure, we detected serum antibodies against acidic glycolipids in 36 of 53 patients with Guillain-Barré syndrome (GBS) and 8 of 16 patients with chronic inflammatory demyelinating polyneuropathy (CIDP). Although we also found anti-acidic glycolipid antibodies in 4 of 13 patients with other neurological diseases; 2 of 10 patients with multiple sclerosis; 8 of 33 patients with inflammatory, infectious, allergic or autoimmune disorders and 3 of 32 healthy subjects, the levels of antibodies in these controls were much lower than in GBS patients. There were several patterns of reactivity of GBS sera including antibodies to LM1 and HexLM1, GM1 or GD1b or both, various other gangliosides, sulfated glycolipids, and as yet unidentified glycolipids. Sera from 30% of GBS patients had antibodies against two or more antigenically distinct acidic glycolipid antigens. Levels of anti-acidic glycolipid antibodies correlated with clinical symptoms in 9 of 11 GBS patients. While the increased incidence of antibodies to acidic glycolipids in patients with GBS (P less than 0.001) and CIDP (P less than 0.025) compared to controls could be an epiphenomenon, anti-acidic glycolipid antibodies may play a role in nerve injury in some GBS and CIDP patients.

Electrophysiologic studies in the Guillain-Barré syndrome: effects of plasma exchange and antibody rebound

Nerve conduction studies (NCS) and antiperipheral nerve myelin antibody (A-PNM Ab) titers were measured serially in 29 patients with Guillain-Barré syndrome (GBS), of whom 21 were treated with plasmapheresis. Data were obtained from 3 to 6 days until 1 to 2 years after onset of symptoms. Within 3 to 6 days, mean NCS were abnormal. They improved some by 1 week and became maximally abnormal by 4 to 8 weeks, during which time A-PNM Ab fell to low levels. In 5 patients plasmapheresed, A-PNM Ab fell and then increased at 4 to 8 weeks, followed by significant deterioration of NCS (P = 0.01) compared with those without antibody rebound at 18 weeks. These results suggest that, in monophasic GBS, there may be two mechanisms of conduction dysfunction such as early paranodal retraction and later demyelination. In some patients plasmapheresed, A-PNM Ab may rebound associated with further conduction dysfunction. These patients may benefit from further plasmapheresis.

High-dose intravenous immune globulin in the management of severe Guillain-Barre syndrome

OBJECTIVE

To evaluate the efficacy of high-dose intravenous gammaglobulin (IGIV) versus plasmapheresis in patients with severe Guillain-Barré syndrome (GBS) and compare the costs of both treatments.

DESIGN

Retrospective review of all severely disabled GBS patients admitted between January 1 and December 31, 1990.

SETTING

Neurologic unit of a tertiary-care center.

PATIENTS

Six patients fulfilling the criteria for the diagnosis of GBS agreed upon by the ad hoc National Institute of Neurological and Communicative Disorders and Stroke committee.

INTERVENTION

Four patients treated with plasmapheresis underwent three to six sessions of plasma exchange. Two patients received IGIV 0.4 g/kg/d administered over a five-day period.

MAIN OUTCOME MEASURES

Recovery time, functional assessment (performed according to the grading scale used in the North American trial) at 30, 60, and 90 days after treatment. Cost of plasmapheresis, IGIV, and bed/day were compared.

RESULTS

Clinical recovery appeared to be faster and more complete in the IGIV group than in the plasmapheresis group. No adverse reactions related to IGIV treatment appeared. The total cost was greater in the plasmapheresis group.

CONCLUSIONS

These preliminary results suggest that IGIV may be more beneficial and less expensive than plasmapheresis in treatment of GBS. Definitive conclusions regarding the efficacy of IGIV in GBS will need to await the final analysis of the Ducht randomized multicenter trial comparing IGIV with plasmapheresis.

Anti-GM1 IgA antibodies in Guillain-Barré syndrome

Serum anti-GM1 IgA antibodies were detected in 15 of 53 (28%) patients with the acute Guillain-Barré syndrome (GBS) and in one of 26 (4%) patients with other neurological diseases. Although nine GBS patients had anti-GM1 IgA titers of 1:200 or less, six patients had titers of 1:800 or more. Some GBS patients with anti-GM1 IgA antibodies also had antibodies against GD1b or GM2 or both. The presence of markedly elevated anti-GM1 IgA was associated with a poor clinical outcome at 6 and 12 months following onset of the GBS. The possible pathogenetic role of anti-GM1 IgA antibodies remains to be established.

Guillain-Barré syndrome. An uncommon but severe illness

It is important for primary care physicians to be familiar with Guillain-Barré syndrome, a relatively rare disorder that may occur after another illness or after stress such as surgery. Although most patients recover fully, respiratory failure and cardiovascular failure are possible complications. Rapid diagnosis and referral to specialists experienced in plasmapheresis therapy can significantly benefit patients.

Antibodies to sulfated glycolipids in Guillain-Barré syndrome

Sera from 53 patients with acute Guillain-Barré syndrome (GBS), 15 patients with chronic inflammatory demyelinating polyneuropathy (CIDP), 13 patients with other neurological diseases (OND) and 31 healthy controls were tested for IgM and IgG antibodies to sulfoglucuronyl paragloboside (SGPG) and sulfatide by both an ELISA and a thin-layer chromatogram-overlay technique. Although the mean levels of anti-SGPG or anti-sulfatide antibodies in GBS patients were not elevated compared to controls, the occurrence of anti-SGPG antibodies was more frequent in GBS patients than in controls (P less than 0.02). Acute GBS patients with antibodies to SGPG or sulfatide were clinically indistinguishable from other GBS patients. Our data suggest that elevated levels of antibodies to SGPG could be important in the pathogenesis of neuropathy in some GBS patients.

Clinical and serological studies in a series of 45 patients with Guillain-Barré syndrome

We retrospectively reviewed the clinical files of 45 Guillain-Barré syndrome (GBS) patients admitted to our Department between 1979 and 1989. The age distribution was bimodal with a first peak in young adults (20-40 years), and a second one between 60 to 70 years. Seasonal distribution showed a late fall and a hivernal predominance. Three patients experienced a second attack of GBS 2-9 years after the first one. Thirty-one (69%) presented antecedent events, most often a respiratory tract infection (n = 20) or enteritis (n = 6). Serological studies were systematically performed, including antibody titers against herpes simplex virus, Epstein-Barr virus, cytomegalovirus (CMV), respiratory syncytial virus, human immunodeficiency virus, Mycoplasma pneumoniae, Campylobacter jejuni/coli and cardiolipin. These studies showed the presence of antibodies indicative of a CMV primary infection in 22% cases and of a Campylobacter jejuni/coli infection in 13%. Co-infection was observed in 3 cases. Serology remained negative in 12 patients with a preceding respiratory infection. There was no correlation between serology and the severity of the disease. Absence of antecedent events and of positive anti-infectious serology was observed in only 10 patients.

P2 specific lymphocyte transformation in Guillain-Barré syndrome and chronic idiopathic demyelinating polyradiculoneuropathy

Thymidine incorporation proliferation assays to whole bovine P2 protein and its 58-81 and 14-25 synthetic peptides were performed on blood mononuclear cells from ten patients with Guillain-Barré syndrome (GBS), six patients with chronic idiopathic demyelinating polyradiculoneuropathy (CIDP), and age and sex matched normal subjects. The only patients whose cells showed any response were two out of four with very early GBS. One responded to P2 and both synthetic peptides. One responded to P2 but to neither peptide. The results support a role for cell mediated immunity to P2 protein in some patients with Guillain-Barré syndrome.

Plasma C3c in immune-mediated neurological diseases: a preliminary report

Plasma C3c levels were examined in 56 patients with immune (27) and non-immune (29) mediated neurological diseases by crossed immunoelectrophoresis. Plasma samples were collected during the active phase of illness in both groups, usually within 7 days of admission. 11 patients (4 Guillain-Barré Syndrome-GBS, 3 chronic inflammatory demyelinating polyneuropathy-CIDP, 4 myasthenia gravis-MG) had their plasma saved sequentially during the active and the recovery phase. Plasma C3c levels were elevated in the group with immune mediated diseases when compared with those of non-immune mediated diseases. The sensitivity and specificity of C3c as a diagnostic test for immune mediated neurological diseases were 61.4 and 100% respectively with a positive and negative predictive value of 100 and 41%. the C3c levels in plasma correlated well with disease severity in MG and GBS patients. Such a correlation was also evident in all CIDP patients except one that had persistent elevation in the presence of clinical improvement. Results suggest that the plasma C3c level may be useful for differentiating immune from non-immune mediated neurological diseases. Plasma C3c may also be used for monitoring disease severity, particularly in myasthenia gravis.

In vitro demyelination by serum antibody from patients with Guillain-Barré syndrome requires terminal complement complexes

Serum from 7 patients who had acute-phase Guillain-Barré syndrome with high anti-peripheral nerve myelin antibody activity (54 to 210 units/ml) was compared with serum from 3 patients in the recovery phase (0 to 17 units/ml) and serum from 7 disease control subjects (0 to 24 units/ml) and 7 normal control subjects (0 to 7 units/ml) for its ability to demyelinate rodent dorsal root ganglion cultures. The demyelinating capacity of each serum was quantitated by counting the percent of damaged internodal segments in each of four cultures. All sera from patients in the acute phase GBS caused 50 to 78% demyelination, in contrast with 6 to 19% by the sera from all 3 patients in the recovery phase and all other control subjects. The degree of demyelination correlated with anti-peripheral nerve myelin antibody activity of the sera and demyelination was complement-dependent. Further, cultures were treated with an immunoglobulin M (IgM) fraction of an acute-phase Guillain-Barré syndrome plasma plus normal human serum depleted of complement component C7. Only those cultures treated with IgM and C7-depleted human serum reconstituted with purified C7 resulted in 50.8% demyelination, which was significantly greater than the 14.2 to 16.2% demyelination observed in the presence of heat-inactivated, C7-depleted human serum plus purified C7 or in the absence of C7 or antibody. In summary, our work suggests that anti-peripheral nerve myelin antibody in Guillain-Barré syndrome mediated complement dependent-demyelination of rodent dorsal root ganglion cultures. Further, this in vitro demyelination required generation of activation complexes of the terminal complement cascade.

Search for antibodies to neutral glycolipids in sera of patients with Guillain-Barré syndrome

Sera from 54 patients with Guillain-Barré syndrome (GBS), 34 patients with other neurological diseases (OND) and 32 healthy controls were tested for antibodies to total lipid fractions and higher neutral glycolipid fractions isolated from human and dog nerves, purified Forssman glycolipid and a panel of purified neutral glycolipids by both an enzyme-linked immunosorbent assay (ELISA) and a thin-layer chromatogram (TLC)-overlay technique. IgM and IgG antibodies to total lipid fractions, as well as to galactocerebroside, ceramide dihexoside, ceramide trihexoside, and globoside were not significantly elevated in the sera of GBS patients as compared to controls. High levels of anti-asialo-GM1 IgG antibodies, however, were detected in 6 of 54 (11%) GBS patients and 1 of 30 (3%) OND patients. Intense reactivity with purified Forssman glycolipid and a number of glycolipid antigens in higher neutral glycolipid enriched fractions of human cauda equina and dog sciatic nerves was noted by TLC-immunostaining in many GBS and control sera. Although the levels of anti-Forssman IgM were significantly decreased in GBS sera compared with normal sera (P less than 0.05) and OND sera (P less than 0.02), the levels of anti-Forssman IgG antibodies were not significantly different. With the possible exception of IgG antibodies to asialo-GM1, our results suggest that serum antibodies against Forssman glycolipid and neutral glycolipids are not significantly elevated in GBS patients and, thus, are unlikely to play an important role in the pathogenesis of this disease.

Treatment of Guillain-Barré syndrome with anti-T cell monoclonal antibodies

Three patients with acute Guillain-Barré syndrome were treated early in the course of the disease with OKT3, an anti-T-cell monoclonal antibody. Each patient developed acute lymphopenia with specific depletion of T3-positive lymphocytes. Two patients had continued progression of clinical deficits for eight and 14 days. This suggests that T lymphocytes may not be essential for progression of Guillain-Barré syndrome at this stage of the disease.

Plasma exchange in Guillain-Barré syndrome: effect on anti-peripheral nerve myelin antibodies

Increased levels of anti-peripheral nerve myelin (anti-PNM) antibodies were demonstrated by ELISA in serum from 4 of 7 patients with Guillain-Barré syndrome (GBS). Treatment with plasma exchange (PE) was performed and 6 of the 7 patients showed clinical improvement with marked increase in muscular strength. One patient, however, continued to deteriorate during the treatment. No correlation between clinical improvement and levels of anti-PNM antibodies was observed. Whether the antibodies are of pathogenetic importance in GBS is therefore still unknown.

Antibody detection in Guillain-Barré syndrome

Chromatograms with appropriate separated ganglioside fractions were overlaid with diluted patient sera, and antibody binding was detected with an alkaline phosphatase-labelled second antibody. Antiganglioside antibodies were present in the sera of 39 of 50 patients with Guillain-Barré syndrome (GBS), in 10 of 12 patients with Alzheimer's disease, and in approximately 30% of the controls. The antibodies were directed against ganglioside 3'-LM1, shown to be the major ganglioside of peripheral nerve (femoral nerve and cauda equina) in most of the positive GBS sera but also in a high proportion in the controls. No correlation was found between the severity or the course of the disease and the antibody titer. Daily parenteral administration of purified bovine brain-derived GM1 ganglioside for three months to 12 patients with Alzheimer's disease did not result in any antiganglioside GM1 antibodies. We have interpreted our findings in the following way. Human sera normally contain naturally occurring antibodies against gangliosides that in general do not cause any tissue damage. Thus, parenteral injection of gangliosides will not lead to any antibody formation.

Characterization of complement-fixing antibodies to peripheral nerve myelin in Guillain-Barré syndrome

Complement-fixing antibodies to peripheral nerve myelin (anti-PNM Ab) can be detected in the serum of patients with Guillain-Barré syndrome (GBS). Kinetics of these antibodies can be correlated with the changing clinical course; the appearance of activation products of the terminal complement cascade in cerebrospinal fluid, serum, and peripheral nerve of patients with GBS; and the ability of GBS serum to mediate complement-dependent demyelination of myelinating cultures of rodent dorsal root ganglion. Some of the anti-PNM Ab in all GBS serum tested thus far bind a neutral glycolipid of human PNM and cross react with Forssman antigen, a cross-species antigen found in many infectious agents. Studies suggest that an IgM antibody in GBS patients that could be triggered by multiple infectious agents binds a surface determinant of a Forssman-like lipid of human PNM and participates in demyelination of peripheral nerve through the activation of complement.

T lymphocyte activation antigens in Guillain-Barré syndrome and chronic idiopathic demyelinating polyradiculoneuropathy

Activated circulating T lymphocytes were measured in ten patients with Guillain-Barré syndrome (GBS) and in ten with chronic idiopathic demyelinating polyradiculoneuropathy (CIDP), each paired with an age- and sex-matched healthy control. Activated T cells were identified by double labelling with phycoerythrin-conjugated anti-CD3 antibody and biotinylated antibodies to activation antigens: human leucocyte antigen (HLA)-DR, transferrin receptor (TFR) or interleukin-2 receptor (IL-2R) visualised with an avidin-biotin-fluorescein system. The frequency of activated T cells was increased in the GBS group. The median of the DR-positive T cells in the patients was 3.4% (range 0.5-9.4%), compared with 1.4% (range 0-4.3%) in the controls (P less than 0.01). For TFR the corresponding medians were 3.3% (range 0.5-6.2%) in the patients and 0% (range 0-2.5%) in the controls (P less than 0.01), and for IL-2R 3.7% (range 0-6.0%) in the patients compared with 0% (range 0-2.9%) in the controls (P less than 0.01). In the CIDP group the median percentage of activated T cells was also increased but the differences were less significant: for DR, patients 2.4% (range 0-3.8%), controls 0.5% (range 0-2.0%, P less than 0.05); for TFR, patients 0% (range 0-5.3%), controls 0% (range 0-1.0%, not significant), and for IL-2R, patients 0% (range 0-2.5%), controls 0% (range 0-0.5%, not significant). The activated cells might be directed against microbial antigens encountered during the infection preceding GBS, autoantigens, bacterial antigens encountered during concurrent infection, or a combination of these.

IgG immunoadsorption in experimental allergic neuritis: effect on antibody levels and clinical course

The effect of IgG immunoadsorption upon the course of chronic experimental allergic neuritis (EAN) is described. Miniature membrane plasma separators coupled with a Protein A (PA)-Sepharose immunoadsorbent column were used to perform upon conscious rabbits 5 IgG immunoadsorption treatments over 6 days. Quantitation of anti-myelin IgG and IgM by ELISA revealed that 55-65% of plasma IgG was removed per treatment. Rapid post-treatment antibody rebound was observed for anti-myelin IgG although no antibody overshoot above control levels could be observed. Anti-myelin IgM levels remained relatively unaffected by PA immunoadsorption. Comparisons of clinical scores between control and treatment animals showed that IgG immunoadsorption was significantly beneficial (day 1 post-treatment p less than 0.001; day 2 post-treatment p less than 0.05). However, rapid relapse was observed in all treatment animals such that by day 3 post-treatment no significant clinical difference between control and treatment groups could be observed. IgG immunoadsorption suppresses the clinical progression of chronic EAN in a manner similar to that seen with plasma exchange. This finding suggests that antibody modulates early disease pathogenesis.

Anti-peripheral nerve myelin antibodies in Guillain-Barre syndrome bind a neutral glycolipid of peripheral myelin and cross-react with Forssman antigen

During acute-phase illness, serum of patients with Guillain-Barre syndrome (GBS) contain complement-fixing antibodies (Ab) to peripheral nerve myelin (PNM). We investigated PNM lipids as putative antigens for these Ab since GBS serum retained significant reactivity to PNM treated with protease. Ab binding to specific lipids was studied with a C1 fixation and transfer (C1FT) assay using fractions of PNM lipid reincorporated into liposomes as antigen targets or to lipids on HPTLC plates with peroxidase-labeled goat Ab to human IgM. Reactivity was detected to a neutral glycolipid (NGL) of human PNM with a similar number of carbohydrates residues to that of Forssman hapten (Forss). Anti-NGL Ab titers in GBS patients (50-220 U/ml) were significantly elevated over disease and normal controls (0-5 and 0-6 U/ml). We studied possible antigenic cross-reactivity of these Ab with Forss by first quantitating Ab activity with C1FT assay and liposomes containing Forss. All 12 GBS sera tested showed titers (54-272 U/ml) significantly elevated over 11 disease controls (0-22 U/ml) and 25 normal controls (0-11 U/ml). GBS serum Ab reacted with Forss isolated from dog nerve or sheep erythrocytes on HPTLC plates. Further, absorption of 80-100% of anti-NGL Ab activity and 17-97% of anti-PNM Ab activity from eight GBS patient serums was accomplished with liposomes containing Forss but not with control liposomes. In seven GBS patients anti-NGL Ab activity represented only a portion of anti-PNM Ab activity. These results suggest that a glycolipid with antigenic cross-reactivity to Forssman hapten may be responsible for some of the anti-PNM Ab activity in GBS.

Motor neuropathy with multifocal conduction blocks

We describe a patient with a chronic, symmetric, monophasic, acquired, pure motor, demyelinating polyneuropathy. Electrodiagnostic studies showed the presence of multifocal conduction blocks in motor nerves at sites not prone to compression. A sural nerve biopsy was normal. The patient responded to immunosuppressive therapy and plasma exchange. We postulate that this disorder is an unusual variant of chronic inflammatory polyradiculoneuropathy.

Membrane plasma exchange in experimental allergic neuritis: effect on antibody levels and clinical course

The effect of membrane plasma exchange on the course of chronic experimental allergic neuritis in rabbits is described. Using miniature membrane plasma separators conscious animals were treated with 4 exchanges over 5 days removing one plasma volume per procedure and using a non-immunogenic gelatin plasma solution as replacement. Comparisons of clinical scores between control and treated groups indicated that treated animals received significant benefit from plasma exchange (day 1 post-treatment P less than 0.002; day 3 post-treatment P less than 0.01). However, relapse was observed in all plasma exchanged animals such that by day 8 post-treatment there was no significant difference in clinical scores between the two groups. Quantitation of anti-myelin IgG and IgM by ELISA assay showed that 55-60% of circulating antibody was removed per exchange. Rapid post-exchange antibody rebound was observed for both IgG and IgM so that pre-exchange levels were re-established within 24-48 h. However, no significant overshoot in circulating levels of anti-myelin IgG nor IgM could be observed. It is probable that long-term remission as a result of therapeutic plasma exchange is a function of effective circulating plasma removal and if present, the suppression of ongoing antigenic stimuli.

Humoral factors in inflammatory disorders of the central and peripheral nervous system

The immune-mediated disorders of the central and peripheral nervous systems all involve humoral mechanisms in which immunoglobulin, complement and/or other mediators are implicated. The disorders can be characterized by pattern of disease activity, site of immunoglobulin synthesis, humoral mechanism of injury, and presence of one or more concurrent cellular mechanisms of injury. Control of the humoral responses is presumably T-cell dependent. While these disorders should be viewed as having both humoral and cellular components, the specific components of each disorder might predict the response to specific therapeutic approaches.

Class and IgG subclass distribution of antibodies against peripheral nerve myelin in sera from patients with inflammatory demyelinating polyradiculoneuropathy

An enzyme-linked immunosorbent assay (ELISA) was used to quantify antibodies against peripheral nerve myelin (PNM) in sera from 90 patients with Guillain-Barré syndrome (GBS) and from 70 patients with chronic inflammatory demyelinating polyradiculoneuropathy (CIDP). Fifty-nine percent of the patients with GBS and 51% of the patients with CIDP had increased levels of anti-PNM antibodies. Antibodies were also found in 0%-14% of sera from patients with other neurological diseases and in 8% of normal blood donors. Mean levels of IgG, IgM and IgA anti-PNM antibodies were increased in sera from patients with GBS, and mean IgG and IgA anti-PNM antibody levels were increased in sera from patients with CIDP when compared with sera from normal blood donors. The mean IgG anti-PNM antibody response observed in patients with GBS or CIDP was dominated by the IgG1 and IgG3 subclasses.

Autoimmunity in neuromuscular disease

A number of confounding factors can be identified from the search for autoimmune mechanisms over the last 2 decades that may be relevant for future studies. (1) An apparently homogeneous clinical disorder may represent more than one disease process and thereby imply antibody/antigen heterogeneity as, for example, in MG with and without detectable anti-AChR antibodies. In some cases, physiologic studies allow the different forms of the disease to be distinguished as in AIDP and acute inflammatory axonal polyneuropathy. (2) A homogeneous disorder (e.g., LEMS) may have at least two different triggering mechanisms (SCLC and an unknown stimulus). (3) Antigen density may be too low to be detected by the immunohistologic techniques available, as initially occurred in MG and LEMS. (4) Autoantibodies may be detected that are irrelevant to the primary disease, such as anti-striated muscle antibodies in MG. (5) Poor antibody cross-reactivity between species may mean that the pathogenic antibody is undetected in binding assays or in experimental passive transfer studies. For example, anti-AChR antibody in MG shows less than 5% reactivity with Torpedo AChR. (6) A poor regenerative capacity of the target antigen may mean that reduction of circulating autoantibodies by either plasma exchange or ISD treatment is not associated with detectable clinical improvement, as may be the case in SSN in which DRG cells appear to be the target. TABLE 5 summarizes the extent to which the data reviewed have established a role for pathogenic antibodies in the light of the postulates for autoimmunity set out earlier and ranks the disorders accordingly. Only in MG with detectable anti-AChR antibody are all the postulates met, including definition of the antigen, experimental passive transfer by the IgG fraction of MG sera, active immunization of experimental animals, and propagation. In both LEMS and the IgM kappa anti-MAG demyelinating neuropathy the antigen is known, although better characterized in LEMS; the epitopes are not yet defined in either. Data relating to passive transfer are more extensive in LEMS, however; systemic passive transfer of anti-MAG has not yet been reported. In neither condition is an animal model available. In the demyelinating neuropathies, the case for autoimmunity is less complete. Neither in AIDP nor in CIDP is the antigen known, and thus the relevance of the different EAN disorders is uncertain. Current evidence thus rests on the demonstration of serum IgM antibodies that react with peripheral nerve myelin and fix complement and on the intraneural passive transfer studies.(ABSTRACT TRUNCATED AT 400 WORDS)

A prospective study of acute idiopathic neuropathy. III. Immunological studies

The immune responses of 100 patients who presented with an acute idiopathic neuropathy were compared with those of age and sex matched controls. Blood lymphocytes and their subsets were counted with a fluorescent activated cell sorter. CD8+ (putative suppressor) lymphocytes were significantly reduced in the first week of the disease but total lymphocytes, total T and CD4+ (putative helper) cells were not altered. This reduction depended on the nature of the preceding infection. Serum complement C3 and C4 concentrations remained normal and immune complexes were rarely detected with a C1q binding assay. Complement-fixing antibodies to human peripheral nerve antigens were discovered in the serum of 7% of patients but only 1% of controls. Complement-fixing antibodies to galactocerebroside were not discovered in any sera. Enzyme-linked immunoassays detected increased antibody responses to galactocerebroside but none at all to human P2 myelin protein in the patient sera. Forty microliter of serum from five patients injected into the sciatic nerves of rats did not induce significantly more demyelination than the serum from control patients. It is concluded that auto-immune responses can only be detected by these techniques in a small minority of patients with acute idiopathic neuropathy.

Serum antibodies to peripheral nerve tissue in acute Guillain-Barré syndrome in relation to outcome of plasma exchange

Mixed haemagglutination and complement fixation tests were used to detect serum antibodies to peripheral nerve in 36 patients with acute Guillain-Barré syndrome. Twenty patients were treated with plasma exchange, 16 served as controls. A significant antibody titre was found in 19 patients with the haemagglutination test; 30 had complement-fixing antibodies. Patients lacking complement-fixing antibodies were less disabled at entry (P less than 0.01). However, there was no correlation between the course of the disease and any of the antibodies in the two patient groups. The two tests were therefore not able to select patients for treatment by plasma exchange.

Serum antibodies to gangliosides in Guillain-Barré syndrome

To determine whether antibodies to acidic glycolipids of nervous tissue are present in patients with Guillain-Barré syndrome (GBS), sera from patients with GBS and appropriate control subjects were tested by a thin-layer chromatogram overlay technique. Chromatograms on which the whole ganglioside fractions from peripheral nerve and brain had been separated were overlaid with appropriate dilutions of the patients' sera (1:100 or greater), and antibody binding was revealed with a radiolabeled or peroxidase-labeled second antibody. Antibodies to ganglioside antigens were detected in 5 of 26 patients with GBS. IgG antibodies in 1 patient reacted strongly with LM1 (sialosyl paragloboside), the major ganglioside of human peripheral nervous system myelin, and its hexaose analog (sialosyl lactosaminyl paragloboside), a minor ganglioside of human peripheral nervous system myelin. The antibody titer in this patient fell 8-fold over 6 weeks coincident with clinical improvement. IgG from 2 other patients with GBS reacted with GD1b ganglioside, and the antibody titers in these patients also decreased substantially with clinical improvement. IgM antibodies in the sera from 2 other patients reacted with GD1a and GT1b gangliosides, which have a shared terminal carbohydrate sequence. Antibodies to gangliosides were not detected in the sera from 19 patients with other neurological diseases or from 10 normal subjects, and the frequency with which antiganglioside antibodies occurred in the patients with GBS was significantly greater than that in the combined control subjects (p less than 0.01). The results demonstrate relatively high levels of antibodies to gangliosides in some GBS patients.

Activation of terminal components of complement in patients with Guillain-Barré syndrome and other demyelinating neuropathies

In the present study, the role of antiperipheral nerve myelin antibody (anti-PNM Ab) in demyelination by generating the terminal attack complex (C5b-9) of complement was explored in patients with Guillain-Barré syndrome (GBS) and other demyelinating neuropathies. The presence in serum of SC5b-9, an inactive C5b-9 containing S protein, was assessed quantitatively by enzyme-linked immunosorbent assay using an antibody (Ab) to neoantigens expressed on C9 when complexed with C5b-8 or after tubular polymerization. SC5b-9 was detected in all 19 GBS, four patients with paraprotein-associated neuropathy and five of six patients with chronic recurrent polyneuritis. No SC5b-9 was detected in 10 normal controls. Kinetic studies from six GBS patients showed the highest values of SC5b-9 on the 3rd to 5th d of admission; in contrast, the anti-PNM Ab were highest on the day of admission. Anti-PNM Ab fell rapidly to very low levels by the 15th to 20th d. SC5b-9 declined with similar kinetics to undetectable levels by the 30th d. Levels of Ab and SC5b-9 did not quantitatively correlate with soluble immune complexes in these patients' serum. Membrane-bound C5b-9 was also detected by immunohistochemistry in the peripheral nerves from a GBS patient. These results, which show a relationship between levels of complement-fixing anti-PNM Ab and the tissue-damaging C5b-9 complex, suggest that peripheral nerve myelin may serve as the target for Ab-mediated complement attack.