Guillain-Barré syndrome

The immunobiology of Guillain-Barré syndromes

This presentation highlights aspects of the immunobiology of the Guillain-Barré syndromes (GBS), the world's leading cause of acute autoimmune neuromuscular paralysis. Understanding the key pathophysiological pathways of GBS and developing rational, specific immunotherapies are essential steps towards improving the clinical outcome of this devastating disorder. Much of the research into GBS over the last decade has focused on the forms mediated by anti-ganglioside antibodies, and we have made substantial progress in our understanding in several related areas. Particular highlights include (a) the emerging correlations between anti-ganglioside antibodies and specific clinical phenotypes, notably between anti-GM1/anti-GD1a antibodies and the acute motor axonal variant and anti-GQ1b/anti-GT1a antibodies and the Miller Fisher syndrome; (b) the identification of molecular mimicry between GBS-associated Campylobacter jejuni oligosaccharides and GM1, GD1a, and GT1a gangliosides as a mechanism for anti-ganglioside antibody induction; (c) the development of rodent models of GBS with sensory ataxic or motor phenotypes induced by immunisation with GD1b or GM1 gangliosides, respectively. Our work has particularly studied the motor nerve terminal as a model site of injury, and through combined active and passive immunisation paradigms, we have developed murine neuropathy phenotypes mediated by anti-ganglioside antibodies. This has been achieved through use of glycosyltransferase and complement regulator knock-out mice, both for cloning anti-ganglioside antibodies and inducing disease. Through such studies, we have proven a neuropathogenic role for murine anti-ganglioside antibodies and human GBS-associated antisera and identified several determinants that influence disease expression including (a) the level of immunological tolerance to microbial glycans that mimic self-gangliosides; (b) the ganglioside density in target tissue; (c) the level of complement activation and the neuroprotective effects of endogenous complement regulators; and (d) the role of calcium influx through complement pores in mediating axonal injury. Such studies provide us with clear information on an antibody-mediated pathogenesis model for GBS and should lead to rational therapeutic testing of agents that are potentially suitable for use in humans.

Anti-phospholipid antibodies in serum from patients with Guillain-Barré syndrome

OBJECTIVE

The Guillain-Barré syndrome (GBS) is an acute inflammatory polyneuropathy related to autoimmunity. However, no conclusive etiological concept has yet been found. We examined the variation in autoantibodies to lipids in serum of GBS patients in response to the course of the disease but investigated titer modifications during treatment with gamma-globulin.

DESIGN AND SETTING

Prospective clinical study in a 14-bed general ICU.

PATIENTS

Nine patients with GBS and nine controls were included in the study.

MEASUREMENTS AND RESULTS

Four blood samples were obtained before and after treatment. Serum samples, diluted 1:60, were tested by enzyme-linked immunosorbent assay for IgM, IgA, and IgG antibodies to phosphatidylcholine, phosphatidylinositol, cardiolipin, phosphatidic acid, phosphatidylserine, phosphatidylglycerol, phosphatidylethanolamine, sphingomyelin, and gangliosides. Anti-phospholipid antibodies of the IgM, IgA, and IgG families were detected in all GBS patients but in none of the controls. Phosphatidylinositol, cardiolipin, phosphatidylcholine, and phosphatidic acid were the main antigens. All patients developed anti-phosphatidylinositol antibodies of the IgM family and anti-cardiolipin antibodies of the IgA and IgG families. A decrease in the level of anti-phospholipid autoantibodies was observed after 1 day of treatment with gamma-globulin. Two days after ending gamma-globulin administration the IgG antibodies increased again.

CONCLUSIONS

Our findings suggest that in GBS there is an extensive immune reaction, which is altered after gamma-globulin treatment. Anti-cardiolipin and anti-phosphatidylinositol antibodies could be useful markers for the response to treatment.

Guillain-Barre syndrome associated with cytomegalovirus infection after allogeneic hematopoietic stem cell transplantation

The association between cytomegalovirus (CMV) infection and the development of Guillain-Barré syndrome (GBS) in the setting of allogeneic hematopoietic stem cell transplantation (alloSCT) has been reported only occasionally. We describe here a 23-year-old patient diagnosed with acute myelogenous leukemia who underwent a partially HLA-mismatched alloSCT and soon after developed GBS along with a CMV infection. Serum autoantibodies to several ganglioside antigens were concomitantly detected. Despite therapy with ganciclovir and plasma exchanges, the patient's clinical condition rapidly deteriorated, and he died 3 weeks later with persisting CMV antigenemia. Although a coincidental association cannot be excluded, it could be speculated that a pathogenetic link exists between the 2 disorders. In this sense, molecular mimicry between viral antigens and neural host tissues could be postulated as the hypothetical mechanism underlying the triggering of the autoimmune disease in the present case.

Treatment of Guillain-Barre syndrome and CIDP

Guillain-Barré syndrome (GBS) and chronic inflammatory demyelinating poly-(radiculo)neuropathy (CIDP) are immune-mediated disorders with a variable duration of progression and a range in severity of weakness. Infections can trigger GBS and exacerbate CIDP. Anti-ganglioside antibodies are important, but there is debate on the role of genetic factors in the pathogenesis of these disorders. Randomized controlled trials (RCT) have shown that intravenous immunoglobulin (IVIg) and plasma exchange (PE) are effective in both GBS and CIDP. Most CIDP patients also improve after steroid therapy. Despite current treatment options, many patients have residual deficits or need to be treated for a long period of time. Therefore, new treatment trials are highly indicated. This review focuses on the current and possible new treatment options that could be guided by recent results from laboratory experiments.

Brucella melitensis infection associated with Guillain-Barré syndrome through molecular mimicry of host structures

Brucella melitensis is a facultative intracellular bacterium that can survive inside macrophages and the causative agent of brucellosis. In the present study, we found that a lipooligosaccharide of B. melitensis has a GM1 ganglioside-like structure and shows a strong antibody response in mice. The cholera toxin B subunit, which binds to GM1 ganglioside specifically, reacted with the surface of B. melitensis. Immunization with B. melitensis induced the production of anti-GM1 ganglioside antibodies in mice and serum from immunized mice showed a cross-reaction with Guillain-Barré syndrome (GBS)-associated Campylobacter jejuni, but not non-GBS-associated C. jejuni. When B. melitensis was treated with a neuraminidase, antibody responses disappeared. B. melitensis immunization induced the production of anti-GM1 ganglioside antibodies in BALB/c mice but not in C57BL/6 and ddY mice, and for BALB/c mice, immunization with B. melitensis induced much greater production of anti-GM1 ganglioside than GBS-associated C. jejuni. Flaccid limb weakness was observed in B. melitensis immunized mice. These results suggest that B. melitensis is a new etiological agent for GBS and that immunological responses between it and GBS-associated C. jejuni in the mouse model may be different.

The use of intravenous immunoglobulin in the treatment of autoimmune neuromuscular diseases: evidence-based indications and safety profile

Intravenous immunoglobulin (i.v.Ig) has multiple actions on the immunoregulatory network that operate in concert with each other. For each autoimmune neuromuscular disease, however, there is a predominant mechanism of action that relates to the underlying immunopathogenetic cause of the respective disorder. The best understood actions of i.v.Ig include the following: (a) modulation of pathogenic autoantibodies, an effect relevant in myasthenia gravis (MG), Lambert-Eaton myasthenic syndrome (LEMS), Guillain-Barré syndrome (GBS), chronic inflammatory demyelinating polyneuropathy (CIDP), and stiff-person syndrome (SPS); (b) inhibition of complement activation and interception of membranolytic attack complex (MAC) formation, an action relevant to the complement-mediated mechanisms involved in GBS, CIDP, MG, and dermatomyositis (DM); (c) modulation of the inhibitory or activation Fc receptors on macrophages invading targeted tissues in nerve and muscle, as seen in CIDP, GBS, and inflammatory myopathies; (d) down-regulation of pathogenic cytokines and adhesion molecules; (e) suppression of T-cell functions; and (f) interference with antigen recognition. Controlled clinical trials have shown that i.v.Ig is effective as first-line therapy in patients with GBS, CIDP, and multifocal motor neuropathy (MMN), and as second-line therapy in DM, MG, LEMS, and SPS. In paraproteinemic IgM anti-MAG (myelin-associated glycoprotein) demyelinating polyneuropathies and inclusion body myositis (IBM), the benefit is variable, marginal, and not statistically significant. i.v.Ig has a remarkably good safety record for long-term administration, however, the following side effects have been observed: mild, infusion-rate-related reactions, such as headaches, myalgia, or fever; moderate but inconsequential events, such as aseptic meningitis and skin rash; and severe, but rare, complications, such as thromboembolic events and renal tubular necrosis. Future studies are needed to (a) find the appropriate dose and frequency of infusions that maintain a response; (b) address pharmacoeconomics, comparing the high cost of i.v.Ig to the cost of the other therapies, which, although less expensive, cause significantly more long-term side effects; (c) determine why some patients respond better than others; and (d) examine the merits of combining i.v.Ig with other immunosuppressive drugs.

Isolated cranial neuropathy associated with anti-glycolipid antibodies

We describe seven patients with isolated cranial neuropathy in whom serum anti-glycolipid antibodies were detected. Trigeminal sensory neuropathy was found in four patients, who had exhibited symptoms for 2 months to 4 years. The other three patients showed facial nerve palsy with or without ophthalmoparesis. Temporal profile analysis of anti-glycolipid antibodies revealed that titers of anti-glycolipid IgM antibodies against GM2 and LM1 gradually decreased in patients having chronic trigeminal sensory neuropathy. In patients with acute trigeminal sensory neuropathy, elevation of anti-LM1 antibody titers continued over 12 months although anti-GalNAc-GD1a antibody disappeared. On the other hand, titers of anti-glycolipid antibodies rapidly decreased in patients with acute facial nerve palsy with or without ophthalmoparesis. We conclude that anti-glycolipid antibodies may play an important role in the development of isolated cranial neuropathy in some patients.

Les urgences neurologiques

Neurological symptoms are a very frequent cause of consultation in emergency units and require consultation with neurologists and neuroradiologists. The most frequent diagnoses are stroke syndrome, seizure, headache, confusion, meningitis and meningo-encephalitis, and facial palsy. The morbidity and mortality of neurological emergencies are strongly related to prompt medical management of the patients which often requires neuroimaging studies. The most common neurological emergencies will be reviewed.

Guillain-Barré syndrome: epidemiology, pathophysiology and management

Guillain-Barré syndrome (GBS) is clinically defined as an acute peripheral neuropathy causing limb weakness that progresses over a time period of days or, at the most, up to 4 weeks. GBS occurs throughout the world with a median annual incidence of 1.3 cases per population of 100 000, with men being more frequently affected than women. GBS is considered to be an autoimmune disease triggered by a preceding bacterial or viral infection. Campylobacter jejuni, cytomegalovirus, Epstein-Barr virus and Mycoplasma pneumoniae are commonly identified antecedent pathogens. In the acute motor axonal neuropathy (AMAN) form of GBS, the infecting organisms probably share homologous epitopes to a component of the peripheral nerves (molecular mimicry) and, therefore, the immune responses cross-react with the nerves causing axonal degeneration; the target molecules in AMAN are likely to be gangliosides GM1, GM1b, GD1a and GalNAc-GD1a expressed on the motor axolemma. In the acute inflammatory demyelinating polyneuropathy (AIDP) form, immune system reactions against target epitopes in Schwann cells or myelin result in demyelination; however, the exact target molecules in the case of AIDP have not yet been identified. AIDP is by far the most common form of GBS in Europe and North America, whereas AMAN occurs more frequently in east Asia (China and Japan). The prognosis of GBS is generally favourable, but it is a serious disease with a mortality of approximately 10% and approximately 20% of patients are left with severe disability. Treatment of GBS is subdivided into: (i) the management of severely paralysed patients with intensive care and ventilatory support; and (ii) specific immunomodulating treatments that shorten the progressive course of GBS, presumably by limiting nerve damage. High-dose intravenous immunoglobulin (IVIg) therapy and plasma exchange aid more rapid resolution of the disease. The predominant mechanisms by which IVIg therapy exerts its action appear to be a combined effect of complement inactivation, neutralisation of idiotypic antibodies, cytokine inhibition and saturation of Fc receptors on macrophages. Corticosteroids alone do not alter the outcome of GBS.

Neuroregenerative and neuroprotective actions of neuroimmunophilin compounds in traumatic and inflammatory neuropathies

FK506 (tacrolimus, Prograf is an immunosuppressant drug that also has profound neuroregenerative and neuroprotective actions independent of its immunosuppressant activity. The separation of these properties has led to the development of non-immunosuppressant derivatives that retain the neurotrophic activity. This review focuses on the peripheral nerve actions of these compounds following mechanical injury (nerve crush or transection with graft repair) and in models of inflammatory neuropathies. Whereas FK506 may be indicative for the treatment of inflammatory neuropathies where its immunosuppressive action would be advantageous, non-immunosuppressant derivatives represent a new class of potential therapeutic agents for the treatment of human neurological conditions in general. Moreover, these studies have led to the discovery of a novel mechanism whereby these compounds activate intrinsic neuroregenerative and neuroprotective pathways in the neuron.

Synthesis of ganglioside epitopes for oligosaccharide specific immunoadsorption therapy of Guillian-Barré syndrome

Guillain-Barré syndrome is a postinfectious, autoimmune neuropathy resulting in neuromuscular paralysis. Auto-antibodies, often induced by bacterial infection, bind to human gangliosides possessing monosialoside and diasialoside epitopes and impair the function of nerve junctions, where these ganglioside structures are highly enriched. Truncated gangliosides representive of GD3, GQ1b and GM2 epitopes have been synthesized as methyl glycosides and as a glycosides of an eleven carbon tether. The synthetic oligosaccharide ligands are structural mimics of these highly complex ganglioside epitopes and via their ability to neutralize or remove auto-antibodies have the potential for therapy, either as soluble blocking ligands administered systemically, or as immuno-affinity ligands for use as extracorporeal immunoadsorbents.

Guillain-Barré syndrome in the course of dengue: case report

This case report describes the findings of a 45-year-old white woman from Brazil, who developed myalgia, fever and macular rash. She was diagnosed as having dengue, based on clinical manifestations and specific IgM titers. One week after the first symptoms of dengue, the patient developed muscle weakness, followed by tetraplegia with areflexia, and respiratory insufficiency. The electromyography had evidence of demyelinating neuropathy and the cerebrospinal fluid showed albuminocytologic dissociation. These neurologic findings were consistent with the diagnosis of Guillain-Barré syndrome. The patient was treated with immunoglobulin and metylprednisolone. Mechanical ventilation was started one week after hospital admission and maintained for four weeks. After six weeks of hospitalization the patient was discharged from the hospital on wheel chair, presenting mild muscle weakness and loss of patellar and ankle reflexes. When the patient was seen at the outpatient service three weeks after hospital discharge she was able to walk with help. This case report suggests a possible association between dengue and Guillain-Barré syndrome.

Is there a decrease in Guillain-Barré syndrome incidence after bovine ganglioside withdrawal in Italy? A population-based study in the Local Health District of Ferrara, Italy

There have been many reports of cases of Guillain-Barré syndrome (GBS) after therapeutic injection of bovine ganglioside preparations with the result that they were withdrawn in Italy in December 1993. As the relationship between bovine gangliosides and GBS has not yet been established, a further epidemiological investigation in the Local Health District (LHD) of Ferrara, Italy, was carried out in the years 1994-2001 to verify whether the incidence of GBS had changed after ganglioside withdrawal. The other aim of this investigation was to update the incidence of GBS in this area since the two previous investigations we carried out showed an increase in incidence from the years 1981-1987 to the years 1988-1993. The cases of GBS were identified prospectively. To guarantee completeness of case ascertainment, an intensive retrospective survey of all possible sources of cases for the entire study period was performed. The mean annual crude incidence rate in the years 1994-2001 (based on 26 new cases) was 1.97 per 100,000 population (95% CI 1.29-2.89), whereas it had been 1.87 per 100,000 population (95% CI 1.35-2.52) in the years 1981-1993 (based on 43 cases) when gangliosides were available. The age-adjusted rates were almost identical (1.66 and 1.65 per 100,000 population, respectively). Although ganglioside administration could have triggered, on the basis of an individual susceptibility, an immunologic reaction which produced GBS, the incidence of GBS in the study area did not change after ganglioside withdrawal. In the whole period 1981-2001, a temporal pattern of incidence was reported with an increase towards a peak in 1990-1992 and a progressive decline thereafter. This temporal pattern did not seem related to ganglioside withdrawal, and no definite explanation for it was found which could imply that the disease incidence is less stable than it was deemed.

Effect of methylprednisolone when added to standard treatment with intravenous immunoglobulin for Guillain-Barré syndrome: randomised trial

BACKGROUND

Despite available treatment with intravenous immunoglobulin (IVIg), morbidity and mortality are considerable in patients with Guillain-Barré syndrome (GBS). Our aim was to assess whether methylprednisolone, when taken with IVIg, improves outcome when compared with IVIg alone.

METHODS

We did a double-blind, placebo-controlled, multicentre, randomised study, to which we enrolled patients who were unable to walk independently and who had been treated within 14 days after onset of weakness with IVIg (0.4 g/kg bodyweight per day) for 5 days. We assigned 233 individuals to receive either intravenous methylprednisolone (500 mg per day; n=116) or placebo (n=117) for 5 days within 48 h of administration of first dose of IVIg. Because age is an important prognostic factor, we split treatment groups into two age-groups-ie, younger than age 50 years, or 50 years and older. Our primary outcome was an improvement from baseline in GBS disability score of one or more grades 4 weeks after randomisation. Analysis was by intention to treat.

FINDINGS

We analysed 225 patients. GBS disability scores increased by one grade or more in 68% (76 of 112) of patients in the methylprednisolone group and in 56% (63 of 113) of controls (odds ratio [OR] 1.68, 95% CI 0.97-2.88; p=0.06). After adjustment for age and degree of disability at entry, treatment OR was 1.89 (95% CI 1.07-3.35; p=0.03). Side-effects did not differ greatly between groups.

INTERPRETATION

We noted no significant difference between treatment with methylprednisolone and IVIg and IVIg alone. Because of the relevance of prognostic factors and the limited side-effects of methylprednisolone, the potential importance of combination treatment with the drug and IVIg, however, warrants further investigation.

Peripheral Neuropathy

This chapter focuses on peripheral neuropathy, which is the third or fourth most common neurologic disorder, even among the elderly. It begins with a description of the classification system for peripheral neuropathies. Because the underlying etiology or precipitating events of peripheral neuropathy are identifiable for the majority of affected individuals, epidemiologic research has largely focused on descriptive studies of disease frequency or on identifying the factors that modify the influence of the already existing risk factors. Three of the most common neuropathies are covered in detail: diabetic neuropathy, carpal tunnel syndrome, and Guillain–Barré syndrome. Each of these conditions is discussed in terms of distribution and risk factors, and is concluded with a discussion of future research directions to address unanswered questions. The chapter emphasizes methodologic approaches that that could be employed to improve the rigor of studies of these conditions.

Advances in understanding and treatment of immune-mediated disorders of the peripheral nervous system

During recent years, novel insights in basic immunology and advances in biotechnology have contributed to an increased understanding of the pathogenetic mechanisms of immune-mediated disorders of the peripheral nervous system. This increased knowledge has an impact on the management of patients with this class of disorders. Current advances are outlined and their implication for therapeutic approaches addressed. As a prototypic immune-mediated neuropathy, special emphasis is placed on the pathogenesis and treatment of the Guillain-Barré syndrome and its variants. Moreover, neuropathies of the chronic inflammatory demyelinating, multifocal motor, and nonsystemic vasculitic types are discussed. This review summarizes recent progress with currently available therapies and--on the basis of present immunopathogenetic concepts--outlines future treatment strategies.

Non-invasive ventilation to avoid tracheal intubation in a patient with Guillain-Barré syndrome

A 72-yr-old man presented with respiratory failure secondary to Guillain-Barré syndrome. Although the criteria for mechanical ventilation were satisfied, the absence of weakness of the bulbar muscles allowed the safe use of non-invasive ventilation for 2 weeks in this patient. Invasive ventilation and tracheostomy were avoided and the patient made a good recovery.

Prospective study of clinical epidemiology of Guillain–Barré syndrome in Harbin, China

Clinical manifestations, outcomes, prognostic indicators, and clinico-epidemiological subgroups were described based on the information of 71 patients with Guillain-Barré syndrome (GBS), who were identified from a prospective survey in Harbin, China during a 1-year period from 1 October 1997 to 30 September 1998. GBS diagnoses of the patients were validated by senior neurologists and most patients were followed up for 6 months after onset. Antecedent events, mainly respiratory infections, were found in 55 (78%) patients during the month before onset. The clinical features, like motor weakness as initial symptoms (82%) and tendon areflexia or hyporeflexia (100%), are similar to those reported from other populations. However, the proportion (70%) of patients reaching to nadir less than 7 days after onset was rather high. Intravenous human immunoglobulin and/or plasmapheresis were used in 45% of the patients and steroids in 58%. At 6 months after onset, 82% of the patients could walk without aid, 46% of the patients had no any residual signs. Four (6%) patients died within 1 month due to respiratory failure. Three subgroups with different clinico-epidemiological characteristics were identified by using cluster analysis. In conclusion, GBS patients in Harbin, China were younger, had shorter time to nadir, frequently preceded by a respiratory infection, and often treated with steroids. Clinical and epidemiological differences of GBS might exist between various populations.

Epidemiology of childhood Guillain-Barré syndrome as a cause of acute flaccid paralysis in Honduras: 1989-1999

The objective of this study was to investigate the incidence of acute flaccid paralysis in the pediatric population of Honduras over an 11-year period, determine what percentage of acute flaccid paralysis was Guillain-Barré syndrome, and identify the epidemiologic features of Guillain-Barré syndrome. There were 546 childhood cases of acute flaccid paralysis seen between January 1989 and December 1999 at the Hospital Escuela Materno-Infantil in Tegucigalpa, Honduras. Of these cases with acute flaccid paralysis, 394 (72.2%) were diagnosed with Guillain-Barré syndrome. Our incidence of Guillain-Barré syndrome in the Honduran pediatric population (1.37/100,000 per year) is higher than that shown in other studies. There was a significantly higher incidence of Guillain-Barré syndrome in younger children (ages 1-4 years), a significant preponderance of cases from rural areas, and a mild predominance in boys but a typical clinical presentation. The Honduran pediatric Guillain-Barré syndrome population had an increased mortality rate. Guillain-Barré syndrome has become the leading cause of childhood paralysis in Honduras. A better understanding of the population at highest risk and opportunities for earlier intervention with more effective therapeutic modalities may permit reducing the mortality among Honduran children who develop Guillain-Barré syndrome.

The ventilated patient undergoing hydrotherapy: a case study

The ascending peripheral neuropathy and paralysis that result from Guillain-Barre Syndrome's (GBS) demyelination of peripheral nerves is a challenge to health professionals; the patient requires support during the acute disease process and during the remyelination recovery period, often lasting months to years. The staff of a major metropolitan teaching hospital's critical care unit (CCU) and physiotherapy departments developed a hydrotherapy treatment programme for a ventilated patient with GBS. Through careful planning and appropriate preparation, it was found that hydrotherapy could successfully and safely be incorporated into a patient's treatment regimen. The benefits included improved range of movement due to the supportive nature of water, anecdotal increased strength, size and movement of remyelinating muscles and a psychological improvement. Although this patient has not recovered from GBS to be independent, hydrotherapy was a valuable part of the treatment regimen and it could be suggested the increase muscle strength lead to improved respiratory function and enabled weaning from ventilation, reducing intensive care length of stay and cost.

Disorders of the respiratory muscles

The act of breathing depends on coordinated activity of the respiratory muscles to generate subatmospheric pressure. This action is compromised by disease states affecting anatomical sites ranging from the cerebral cortex to the alveolar sac. Weakness of the respiratory muscles can dominate the clinical manifestations in the later stages of several primary neurologic and neuromuscular disorders in a manner unique to each disease state. Structural abnormalities of the thoracic cage, such as scoliosis or flail chest, interfere with the action of the respiratory muscles-again in a manner unique to each disease state. The hyperinflation that accompanies diseases of the airways interferes with the ability of the respiratory muscles to generate subatmospheric pressure and it increases the load on the respiratory muscles. Impaired respiratory muscle function is the most severe consequence of several newly described syndromes affecting critically ill patients. Research on the respiratory muscles embraces techniques of molecular biology, integrative physiology, and controlled clinical trials. A detailed understanding of disease states affecting the respiratory muscles is necessary for every physician who practices pulmonary medicine or critical care medicine.

Effect of human immunodeficiency virus on intensive care unit outcome of patients with Guillain-Barré syndrome

OBJECTIVES

The primary objective of this study was to investigate the effect of human immunodeficiency virus (HIV) infection on the outcome of patients admitted to the intensive care unit (ICU) with severe Guillain-Barré syndrome (GBS) requiring mechanical ventilation. A secondary objective was to compare the clinical and laboratory features of HIV-seronegative and HIV-seropositive patients admitted to the ICU with severe GBS.

DESIGN

Retrospective chart review.

SETTING

Two tertiary, academic hospitals in Johannesburg, South Africa.

MATERIALS AND METHODS

The case records of all patients admitted to the ICU with GBS between January 1995 and June 2002 were reviewed. Patients were included if their HIV status was known and if they had clinical features, electrophysiologic studies, and cerebrospinal fluid analyses consistent with GBS. Demographic data, days in ICU, days ventilated, CD4 T-lymphocyte counts (in the HIV group), cerebrospinal studies, infection rate, and mortality data were analyzed.

RESULTS

A total of 13 patients met the inclusion criteria: seven were HIV seronegative and six were HIV seropositive. The median age in the HIV group was 34.5 yrs, compared with 47 yrs in the non-HIV group. There was no significant difference between the two groups in days spent in the ICU or days ventilated. There were no significant differences in cerebrospinal studies, electrophysiologic studies, and blood culture-positive infections between the two groups. All patients received intravenous immunoglobulin (0.4 g/kg/day for 5 days). There was one death in the HIV-seropositive group and no deaths in the HIV-seronegative group. The median CD4 T-lymphocyte count in the HIV group was 322.5 x 106 cells/L.

CONCLUSION

HIV is commonly associated with GBS in South Africa. The ICU outcome in patients with HIV-associated GBS is similar to HIV-seronegative patients, particularly if the CD4 T-lymphocyte count is greater than 200 x 106 cells/L at admission.

Anti-GM1 IgG antibodies induce leukocyte effector functions via Fcgamma receptors

Guillain-Barré syndrome (GBS) is an immune-mediated neuropathy, in which leukocytes and humoral components of the immune system proposedly initiate localized inflammation. An important pathogenic role for anti-GM1 ganglioside antibodies has been suggested. Therefore, we evaluated anti-GM1 IgG antibody-induced leukocyte effector functions such as degranulation and phagocytosis using serum of 24 GBS patients. Serum without anti-GM1 antibodies of 9 GBS patients as well as pooled serum from healthy individuals served as controls. Ten out of 15 (67%) of anti-GM1 IgG positive sera were capable of inducing leukocyte degranulation, and 8 out of 15 (53%) of anti-GM1 IgG positive sera were capable of inducing phagocytosis of GM1-coated beads. In all of these sera anti-GM1 antibody titers were >or=1:800. No leukocyte degranulation or phagocytosis was observed in control sera. Leukocyte activation was completely abrogated in the presence of IgG receptor (FcgammaR) blocking antibodies, suggesting a crucial role for leukocyte FcgammaR in GBS pathogenesis. No correlation of antibody titers with the extent of leukocyte activation, or severity of disease was observed. These data document the capacity of anti-GM1 IgG antibodies to activate leukocyte inflammatory functions, and suggest an important role for anti-ganglioside IgG antibodies in the pathogenesis of GBS.

Recovery from depression associated with Guillain Barré syndrome

Guillain Barré Syndrome is a rare disease, affecting primarily, but not solely, the peripheral nervous system. Because it is rare, many physicians, nurses, and health care practitioners see few cases in their careers. A case study, in which the patient/author was not diagnosed for approximately a year, is interesting because of associated depression. Recovery from depression is not simple. The steps achieved by the author took a great deal of effort. However, mental health nurses could play a more active role in raising questions for patients without a diagnosis or with evidence of mental confusion, and in assuring empathetic regard.

Demyelination and axonal loss in multifocal motor neuropathy: distribution and relation to weakness

Multifocal motor neuropathy (MMN) is characterized by a slowly progressive, asymmetric weakness of the limbs without sensory loss. The arms are usually affected to a greater extent than the legs, and distal muscles more than proximal muscles. The distribution of electrophysiological abnormalities and its correlation with weak muscle groups in MMN have not been investigated systematically. The aim of the present study was to assess whether electrophysiological abnormalities have a preferential or random distribution, whether electrophysiological abnormalities in a nerve correlate with weakness in the innervated muscles, and whether these results are relevant for the development of optimal electrodiagnostic protocols. We compared the pattern of weakness and electrophysiological abnormalities in 39 patients with a lower motoneuron syndrome and a positive response to intravenous immunoglobulins. All patients underwent an extensive standardized electrophysiological examination. Electrophysiological evidence of demyelination was found more often in the nerves of the arms and was distributed randomly over lower arm, upper arm and shoulder segments. Electrophysiological evidence of axonal loss presented more frequently in longer nerves, occurring most often in the leg nerves. For the arm nerves, it is possible that the length dependence of axonal loss is due to the random distribution of demyelinating lesions that lead to axonal degeneration. Weakness was associated with features of demyelination and axonal loss in the nerves of the arm, and with features of axonal loss in leg nerves. However, a substantial number (approximately one-third) of electrophysiological abnormalities were found in nerves innervating non-weakened muscles. These results imply that in MMN, conduction block is most likely to be found in long arm nerves innervating weakened muscles, but if conduction block cannot be detected in these nerves, the electrophysiological examination should be extended to other arm nerves including those innervating non-weakened muscles.

Major surgery with Guillain-Barré syndrome: a case report

Guillain-Barré syndrome (GBS) is an acute demyelinating polyneuropathy characterized by progressive muscle weakness and areflexia. The pathogenesis of GBS is unknown, but it is generally believed to result from aberrant humoral and cellular immune responses against components of the peripheral nervous system. The overall prognosis of GBS is quite good with approximately 85% of survivors making a good functional recovery. When a diagnosis of GBS has been made, appropriate treatment should be started as early as possible. This may include supportive care in intensive care units, ventilatory assistance, monitoring of blood pressure, fluid status, cardiac rhythm, nutritional supports and medical therapy. Our patient reached maximum deficiency 3 weeks after the onset of GBS. Full recovery took 8 months. The occurrence of GBS after major surgery is rare. We believe that major surgical stress may be the potential triggering factor for the occurrence of GBS in this case report.

Treatment of immune neuropathies

PURPOSE OF THE REVIEW

Guillain-Barré syndrome (GBS), chronic inflammatory demyelinating poly(radiculo)neuropathy (CIDP) and multifocal motor neuropathy (MMN) are potentially treatable disorders. The use of appropriate assessment scales to evaluate the effects of treatment is essential. Recent therapeutic trials and the question of whether patients with mild disease or other variants of these disorders need to be treated are discussed.

RECENT FINDINGS

Recent clinical trials and Cochrane reviews give new information on the effect of various treatments in patients with GBS, CIDP and MMN. Intravenous immunoglobulin remains the only treatment proven to be effective in MMN. Combinations of treatment may be even more effective in GBS. Studies on prognostic factors related to improvement have been reported. Whether patients with Miller-Fisher syndrome or those with mild GBS should also be treated is still debated. New assessment scales at the disability and handicap level have now been evaluated for GBS and CIDP, and are ready for use. Results of studies in experimental models contribute to our understanding of the mechanism of action of intravenous immunoglobulin.

SUMMARY

Recent new information on the use of intravenous immunoglobulin and steroids indicates that the former should remain the cornerstone of treatment for GBS and MMN, and probably also for CIDP. Whether steroids not only suppress disease activity in CIDP but also eradicate the disease remains to be established. Some GBS patients have secondary deterioration or finally turn out to have CIDP; additional information in this group of patients may lead to more appropriate disease management. Most patients with CIDP and those with MMN need long-term treatment. New treatment strategies should now focus also on the effect and the costs of treatment over long-term follow up.

A case-case comparison of Campylobacter coli and Campylobacter jejuni infection: a tool for generating hypotheses

Preventing campylobacteriosis depends on a thorough understanding of its epidemiology. We used case-case analysis to compare cases of Campylobacter coli infection with cases of C. jejuni infection, to generate hypotheses for infection from standardized, population-based sentinel surveillance information in England and Wales. Persons with C. coli infection were more likely to have drunk bottled water than were those with C. jejuni infection and, in general, were more likely to have eaten pâté. Important differences in exposures were identified for these two Campylobacter species. Exposures that are a risk for infection for both comparison groups might not be identified or might be underestimated by case-case analysis. Similarly, the magnitude or direction of population risk cannot be assessed accurately. Nevertheless, our findings suggest that case-control studies should be conducted at the species level.

Tolerance to self gangliosides is the major factor restricting the antibody response to lipopolysaccharide core oligosaccharides in Campylobacter jejuni strains associated with Guillain-Barré syndrome

Guillain-Barré syndrome following Campylobacter jejuni infection is frequently associated with anti-ganglioside autoantibodies mediated by molecular mimicry with ganglioside-like oligosaccharides on bacterial lipopolysaccharide (LPS). The regulation of antibody responses to these T-cell-independent antigens is poorly understood, and only a minority of Campylobacter-infected individuals develop anti-ganglioside antibodies. This study investigates the response to gangliosides and LPS in strains of mice by using a range of immunization strategies. In normal mice following intraperitoneal immunization, antibody responses to gangliosides and LPS are low level but can be enhanced by the antigen format or coadministration of protein to recruit T-cell help. Class switching from the predominant immunoglobulin M (IgM) response to IgG3 occurs at low levels, suggesting B1-cell involvement. Systemic immunization results in poor responses. In GalNAc transferase knockout mice that lack all complex gangliosides and instead express high levels of GM3 and GD3, generation of anti-ganglioside antibodies upon immunization with either complex gangliosides or ganglioside-mimicking LPS is greatly enhanced and exhibits class switching to T-cell-dependent IgG isotypes and immunological memory, indicating that tolerance to self gangliosides is a major regulatory factor. Responses to GD3 are suppressed in knockout mice compared with wild-type mice, in which responses to GD3 are induced specifically by GD3 and as a result of polyclonal B-cell activation by LPS. The anti-ganglioside response generated in response to LPS is also dependent on the epitope density of the ganglioside mimicked and can be further manipulated by providing secondary signals via lipid A and CD40 ligation.

Complex gangliosides as autoantibody targets at the neuromuscular junction in Miller Fisher syndrome: a current perspective

Glycosphingolipid biology has increasingly interfaced with the field of human autoimmune neuropathy over the last two decades. There are currently over 20 distinct glycolipids that have been identified as autoantibody targets in a wide range of clinical neuropathy syndromes. This review sets out the clinical and experimental background to one interesting example of anti-glycolipid antibody-associated neuropathy termed Miller Fisher syndrome. This syndrome, comprising the triad of ataxia, areflexia, and ophthalmoplegia, correlates highly with the presence of serum anti-GQ1b antibodies, arising through molecular mimicry with microbial oligosaccharides. Anti-GQ1b antibodies mediate neural injury through binding to GQ1b-enriched sites in the peripheral nervous system, including extraocular nerves. Animal experimental evidence, along with a hypothetical background, indicates the motor nerve terminal may be a key site for anti-GQ1b antibody binding with consequent defects in synaptic transmission, as occurs in botulism and other toxinopathies. Our work in recent years on this hypothesis is summarized.

Detection of anti-ganglioside antibodies in Guillain-Barré syndrome and its variants by the agglutination assay

Sera from 40 patients with Guillain-Barré syndrome (GBS), including the subtypes acute inflammatory demyelinating polyneuropathy (AIDP), acute motor axonal neuropathy (AMAN), acute motor and sensory axonal neuropathy (AMSAN), and Miller Fisher syndrome (MFS) were examined for the presence of anti-ganglioside antibodies using the ganglioside agglutination assay, and the enzyme-linked immunosorbent assay (ELISA). In the ELISA system, sera were tested for IgM and IgG antibodies to GM1, GM2, GD1a, GD1b, GT1b, and GQ1b gangliosides. Antibodies to gangliosides were detected in 21 (53%) of the GBS patients by agglutination assay and in 17 (43%) of the patients by ELISA. Some of the sera reacted with more than one ganglioside. Antibodies were not found in the control sera that were studied. The agglutination assay may be useful for rapid screening of GBS sera for antibodies to multiple gangliosides.

Motor conduction studies in Miller Fisher syndrome with severe tetraparesis

Some patients with Miller Fisher syndrome (MFS) have a severe tetraparesis such as that observed in Guillain--Barré syndrome (GBS). To determine whether pathophysiologic differences exist between the tetraparesis in MFS and that in GBS, we compared clinical and motor conduction findings in 4 MFS patients who developed severe tetraparesis with those in 5 MFS patients without tetraparesis, and 14 GBS patients. MFS patients with or without tetraplegia had normal motor conduction velocities, distal motor latencies, compound muscle action potential (CMAP) amplitudes, and F-wave latencies. CMAP amplitude tended to be lower in tetraparetic MFS patients than in MFS patients without tetraparesis, but not significantly. F-wave occurrence was slightly reduced in 1 MFS patient with tetraparesis and 1 MFS patient without tetraparesis. Motor conduction parameters were abnormal in 13 of 14 patients with GBS, and showed demyelinating features in 10. Our results suggest that the pathophysiology of tetraparesis in MFS differs from that in GBS.

Guillain-Barré syndrome after allogeneic hematopoietic stem cell transplantation

Guillain-Barré syndrome is a rare complication in the setting of hematopoietic stem cell transplantation. We report three children with T cell lymphoma/leukemia in whom this syndrome developed soon after they received unrelated donor transplants. The rapid onset of symptoms raises the concern that the bone marrow transplant conditioning regimen (ie, total body irradiation, cyclophosphamide and cytosine arabinoside) might have precipitated the clinical syndrome of ascending polyneuropathy. Although central nervous system toxicity has been well described with high-dose cytosine arabinoside therapy, peripheral neuropathy of the Guillain-Barré type has been reported only infrequently. We review possible factors contributing to the development of this syndrome in these three patients.

Antibodies against gangliosides: a link between preceding infection and immunopathogenesis of Guillain-Barré syndrome

Autoantibodies against gangliosides GM1 and GQ1b, characteristic cell surface glycolipids of the nervous system, are present in specific clinical types of GuillainBarré syndrome (GBS). Close associations of anti-GM1 with acute motor axonal neuropathy, and of anti-GQ1b with Miller Fisher syndrome, strongly suggest that these antibodies contribute to neuropathy pathogenesis. Immune responses against gangliosides are suspected to originate as a result of molecular mimicry between gangliosides and lipopolysaccharides of Campylobacter jejuni, the most frequent infectious trigger of GBS. Thus, antibodies against gangliosides may link C. jejuni infection with the precipitation of neurological disease.

Miller Fisher syndrome in adult onset Still's disease: case report and review of the literature of other neurological manifestations

Adult-onset Still's disease (AOSD) is a multi-system inflammatory disorder characterized by high spiking fevers, evanescent salmon-coloured rash, arthralgias or arthritis, hepatosplenomegaly, lymphadenopathy and sore throat. There is no specific test or combination of tests that can establish the diagnosis of AOSD and patients may present with other systemic involvement including neurological manifestations in 7-12% of cases. We present a complex case of a patient with AOSD who developed the Miller-Fisher variant of Guillain-Barré syndrome. This immunological disorder of the nervous system has not been described in association with AOSD before. We also review the literature on other neurological manifestations in AOSD. AOSD mimics different disease processes and its multi-system manifestations may complicate the picture further.

Assessment of experimental autoimmune neuritis in the rat by electrophysiology of the tail nerve

The assessment of experimental autoimmune neuritis (EAN) by electrophysiological studies of the sciatic innervation of the plantar muscle may be complicated by local inflammation. We therefore utilized the tail nerve-muscle system to monitor disease progression in 20 rats with EAN and 10 control rats. Early changes were detected in motor nerve conduction velocity (32.06 +/- 1.85 m/s versus 43.57 +/- 3.98 m/s in controls, P < 0.001) at 15 days postimmunization (DPI), and conduction block (70.6 +/- 9.4% compared to 12.4 +/- 3.4%, P < 0.001) at 22 DPI. No consistent conduction block (22.4 +/- 10.4%) was found in the plantar muscle measurements. The tail nerve response of EAN rats demonstrated severe temporal dispersion at 43 DPI, which returned to normal at 135 DPI, although motor nerve conduction velocity values were still lower than in controls (24.4 +/- 0.9 m/s, P < 0.001). The tail nerve may be a useful addition to electrophysiological studies in this model of the Guillain-Barré syndrome.

Progress in Guillain-Barré syndrome

This editorial review summarizes and critically analyses reports published in the preceding 18 months on the pathogenesis of Guillain-Barré syndrome, with particular emphasis on the role of ganglioside antibodies, antecedent infections, and the concept of molecular mimicry. It concludes with an appraisal of currently available and proposed therapies.

Epidemiology of the Guillain-Barré syndrome

This review focuses on recent epidemiological findings on Guillain-Barré syndrome regarding incidence, antecedent events related to the disease, prognosis and prognostic indicators, and treatment. Moreover, this review summarizes recent observations on clinical variants of Guillain-Barré syndrome and their relationship with the prevailing clinical presentation of the disease. The epidemiological observations which have advanced the understanding of the pathogenesis of Guillain-Barré syndrome are also discussed.

P0 protein is a target antigen in chronic inflammatory demyelinating polyradiculoneuropathy

Chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) is widely regarded as an autoimmune disorder, although the autoantigen remains unknown. In this study, the sera of 21 CIDP patients were examined by immunofluorescence for antimyelin activity and by Western blotting for binding to myelin proteins. Six sera contained anti-P0 immunoglobulin G antibodies, and four of these caused conduction block and demyelination following intraneural injection in experimental animals. Absorption with P0 protein eliminated the demyelinating activity. These results show that P0 is an autoantigen in some patients with CIDP. Since P0 possesses powerful adhesion properties and is largely responsible for myelin compaction, the demonstration of demyelination by human anti-P0 antibodies provides new insight into this important and common immunopathological process.

[Acute motor axonal neuropathy and aseptic meningitis due to Staphylococcus aureus endocarditis]

INTRODUCTION

Central nervous system complications are commonly described in Staphylococcus aureus endocarditis but peripheral nervous system involvement is rare.

EXEGESIS

We report the case of a 65-year-old woman who had tetraparesia and aseptic meningitis revealing S. aureus endocarditis. The presence of purpura on the lower limbs led to an initial diagnosis of meningococcal meningitis. Tetraparesia was due to an acute motor axonal neuropathy. Anti-GM1 antibodies were negative. Meningitis and tetraparesia improved with antibiotic therapy.

CONCLUSION

Acute motor axonal neuropathy may be a presenting symptom of S. aureus endocarditis.