Chronic relapsing polyneuritis

Chronic inflammatory demyelinating polyradiculoneuropathy associated with pregnancy

In a series of 61 patients with the relapsing variety of chronic inflammatory demyelinating polyneuropathy, there were 16 women of childbearing age, 9 of whom became pregnant. In 4 of these women, the onset of neuropathy occurred in pregnancy and in the other 5 relapses occurred during pregnancy. There was a significant increase in the number of relapses during the year of pregnancy, and a tendency for symptoms to worsen during the third trimester or immediate postpartum period. It is concluded that there is an increased risk of relapse of chronic inflammatory demyelinating polyneuropathy in pregnancy.

A case of Dejerine-Sottas disease with prominent ataxia and brain stem involvement. A clinical, electrophysiological, otoneurologic, and ultrastructural study

A case is presented of Dejerine-Sottas disease in a 12-year-old boy in which clinical signs made diagnosis of Friedreich's ataxia seem plausible. Based on marked slowing of motor conduction velocity, the sural nerve biopsy findings of a hypertrophic neuropathy with hypo- and demyelination of the nerve fibres, as well as the clinical history, the diagnosis of Dejerine-Sottas disease was made. ABR examination suggested involvement of brain stem at the roots and/or nuclei of the eighth cranial nerve, without involvement of higher structures.

Class II antigen expression and T lymphocyte subsets in chronic inflammatory demyelinating polyneuropathy

The inflammatory infiltrate within human sural nerve, biopsied from six patients with active chronic inflammatory demyelinating neuropathy (CIDP) was studied for T lymphocyte subsets and Class II antigen (Ia)-expressing cells. Immunohistochemical staining with mouse monoclonal antibodies, acid phosphatase staining, and electron microscopy were used to provide an alternative assessment of macrophage and other mononuclear cell numbers. In normal control nerves Class II antigen was present upon endothelial cells, very occasional mononuclear cells and sparsely within the perineurium. In CIDP nerve dense Class II antigen staining was prominent within nerve fascicles, in capillary endothelial cells and within the perineurium. T lymphocytes of suppressor and helper type were present in small numbers only. Moderate numbers of macrophage-monocytes were found in the patients within nerve fascicles but these cells accounted for only part of the dense Ia staining. Since two nerves with hypertrophic changes, Schwann cells forming 'onion bulbs', were clearly Ia positive, the dense and widespread staining in all nerves studied is best explained by Ia antigen expression upon mononuclear and some Schwann cells.

Clinical significance of serum and CSF findings in the Guillain-Barré syndrome and related disorders

Clinical data and the serum and cerebrospinal fluid (CSF) findings of 71 patients with Guillain-Barré syndrome (GBS), 7 with Fisher syndrome and 24 with chronic inflammatory polyradiculoneuropathy (CIP), were analysed. Isoelectric focusing of serum and CSF together with different formulae and diagrams were applied to study blood-CSF barrier (BCB) function and possible intrathecal IgG synthesis. The CSF total protein concentration and its IgG percentage depended mainly on the degree of BCB damage, which correlated with the clinical course. Our investigations suggest that oligoclonal IgG of CSF from these patients comes essentially from serum. In the group of GBS patients, oligoclonal IgG was transitory and correlated significantly with the development of BCB damage, cranial neuritis and severity of the disease. CIP patients showed a stable IgG pattern, which varied slightly after immunosuppressive therapy.

Chronic inflammatory demyelinating polyneuropathy of infancy: a corticosteroid-responsive disorder

We present the clinical, electrophysiological, and histopathological findings in 6 children with early-onset chronic inflammatory demyelinating neuropathy. The clinical features initially suggested a genetically determined disorder in each patient. Sural nerve biopsy showed changes of chronic demyelination with multifocal endoneurial edema and mononuclear cellular infiltrates. All children improved with corticosteroid therapy.

Plasma exchange in chronic inflammatory demyelinating polyradiculoneuropathy

Plasma exchange has been reported to be efficacious in chronic inflammatory demyelinating polyradiculoneuropathy. We performed a prospective double-blind trial in which patients with static or worsening disease were randomly assigned to plasma exchange (n = 15) or to sham exchange (n = 14) for three weeks. After three weeks, we observed statistically significant differences in combined measurements of nerve conduction (total, motor, proximal, velocity, and amplitude) favoring patients who had received plasma exchange. Improvement to a greater degree than for any patient receiving sham exchange was detected in the neurologic-disability score in five patients (P = 0.025) and in subset scores for weakness and reflex in four patients (P less than 0.057). We conclude that for some patients with chronic inflammatory demyelinating polyradiculoneuropathy, plasma exchange has an ameliorating effect on neurologic dysfunction and nerve conduction, but in others no improvement is observed. Because plasma was replaced with normal serum albumin, a humoral factor or factors may have a role in the neurologic deficit of this disorder.

Chronic inflammatory demyelinating polyneuropathy in two siblings

A familial occurrence of chronic inflammatory demyelinating polyneuropathy is reported. The diagnostic problems in distinguishing the progressive form of this disease in childhood from hereditary motor and sensory neuropathy types I and III are discussed. Criteria for a definite diagnosis of chronic inflammatory demyelinating polyneuropathy are proposed.

Relapsing inflammatory demyelinating polyneuropathy in a diabetic patient

Inflammatory demyelinating polyradiculoneuropathies exhibit well-known ultrastructural lesions of the peripheral nerve, both in acute cases, i.e., Guillain-Barré syndrome, and in relapsing, sub-acute and chronic cases. We present a case of relapsing inflammatory demyelinating polyradiculoneuropathy in a diabetic patient with a biopsy exhibiting these lesions, as well as a widening of the outermost myelin lamellae in some fibers. Such associated lesions are classic in experimental inflammatory demyelinating polyradiculoneuropathies, but have not been reported in human pathology.

Treatment of peripheral neuropathies

There are three general approaches to treatment of peripheral neuropathy. First, an attempt should be made to reverse the pathophysiological process if its nature can be elucidated. Second, nerve metabolism can be stimulated and regeneration encouraged. Third, even if the neuropathy itself cannot be improved, symptomatic therapy can be employed. This review outlines the options available for each approach.

Plasma and gamma-globulin infusion in chronic inflammatory polyneuropathy

We treated 17 patients with chronic inflammatory polyneuropathy (CIP) with infusions of fresh-frozen plasma (FFP). Thirteen patients had a beneficial response: 12 improved considerably and one moderately. The first signs of improvement were seen within 8 days of the onset of treatment. None of these patients had had spontaneous remissions for 2 months prior to treatment, and none had received immunosuppressive medication during the plasma infusions. The treatment effect was short-lasting in 9 patients. Re-institution of the FFP infusions was always followed by improvement. The same effect could be achieved by intravenous gamma-globulin. We conclude that infusions with FFP, of which the IgG fraction is the effective part, may induce a rapid and clinically important improvement in patients with CIP.

Alpha-1 antitrypsin phenotypes in demyelinating disease: an association between demyelinating disease and the allele PiM3

Alpha-1 Antitrypsin, the major circulating protease inhibitor, has more than thirty alleles that can be identified by electrophoresis. In addition to its role as a protease inhibitor, alpha-1 antitrypsin may regulate the immune response. As there is evidence that both the inflammatory polyneuropathies and multiple sclerosis have an immune basis, and that genetic factors influence susceptibility, we have determined the alpha-1 antitrypsin phenotypes (protease inhibitor types) of 63 patients with Guillain-Barré syndrome, 52 patients with chronic inflammatory demyelinating polyneuropathy, and 178 patients with multiple sclerosis. In all 3 groups there was a significant increase in the proportion of patients with the protease inhibitor type M3 allele.

Posttraumatic autoimmune reaction in peripheral nerve: effect of a single injury

This study was conducted to show that local autoimmune reactions could be observed in rat sciatic nerve after a single injury. Furthermore, we attempted to correlate the intensity of the immunological reaction with the severity of nerve damage, with the type of surgical treatment and with the degree of functional recovery. Through the use of direct immunofluorescence techniques, we found that the severity of the initial damage was associated with the intensity of the local immunological response assessed 2.5 months after surgery. There was an association between type of surgical treatment and intensity of the autoimmune reaction. A correlation between autoimmune reaction and degree of long-term functional impairment was not immediately clear. The probable factors that underlie these results are discussed.

Chronic experimental allergic neuritis (EAN) in juvenile guinea pigs: immunological comparison with acute EAN in adult guinea pigs

In order to approach the mechanism of chronic or relapsing course in human chronic inflammatory demyelinating polyradiculoneuropathy, we established a chronic model of experimental allergic neuritis (EAN) in juvenile guinea pigs, and investigated the underlying cellular immune phenomenon in comparison with acute EAN in adult animals of the same strain. Two-week-old Hartley guinea pigs, sensitized with bovine peripheral nerve homogenate, developed chronic or relapsing EAN, whereas all adult animals developed acute monophasic EAN. Morphological examination of both the chronic and acute forms revealed scattered demyelination and mononuclear cell infiltrates which were essentially restricted to the peripheral nervous system, and indistinguishable from each other. Both the in vitro lymphocyte mitogenic response and in vivo skin testing revealed a significantly lower response to neuritogenic antigens (P2 protein and peripheral nerve myelin) in juvenile chronic EAN than in adult acute EAN throughout their respective courses. In addition, we showed, by means of assessing peripheral blood lymphocyte number and its subpopulations, that normal 2-week-old Hartley guinea pigs have not fully developed immunologically. These observations suggested that there was some immunological incompetence especially in cellular immunity in 2-week-old juvenile guinea pigs and that this might be one possible factor leading to chronic EAN.

Plasma exchange in chronic inflammatory demyelinating polyradiculoneuropathy

Eleven consecutive patients with progressive chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) underwent plasma exchange. Eight patients were previously unresponsive to prednisone, two were started on prednisone with plasma exchange, and one did not receive corticosteroids. Electrodiagnostic studies revealed evidence of an acquired demyelinating polyradiculoneuropathy with varying degrees of axonal degeneration. Neurologic impairment was monitored using conventional functional status index. Five patients demonstrated substantial clinical improvement, beginning 2 days to 3 weeks after initiating plasma exchange. Two additional patients improved following a second course of plasma exchange, and four patients demonstrated minimal or no change. Comparison of responding and nonresponding patients showed no differences related to the presence or absence of antecedent illness, duration of disease, duration of maximum weakness, or severity of impairment prior to plasma exchange. Responders had significantly prolonged F-response and motor distal latencies compared to nonresponders. Results in this unselected, consecutive patient trial suggest a temporal relationship between plasma exchange and clinical improvement in some patients with progressive CIDP.

Treatment of refractory chronic demyelinating polyneuropathy with lymphoid irradiation

Four patients with refractory or poorly responsive chronic progressive demyelinating polyneuropathy (CPDP) were treated with total lymphoid irradiation (total dose, 2000 rad) in an uncontrolled feasibility study. All patients had previously failed conventional therapy for CPDP, as well as other unconventional treatments. During a follow-up period of 7 to 12 months after total lymphoid irradiation, there was a profound and sustained suppression of the absolute lymphocyte count and in vitro lymphocyte function, as well as an increase in the ratio of Leu-2 (suppressor/cytotoxic subset) to Leu-3 (helper/inducer subset) T cells in the blood. Three of the four patients demonstrated improvement in distal muscle strength, and this was associated with increased functional capabilities in two patients. In contrast, no clinical improvement in sensation was noted in any patient. Nerve conduction studies showed patchy improvement in three patients. The results of this preliminary uncontrolled study indicate that radiotherapy deserves further study in the treatment of CPDP.

Paraproteinemia associated with demyelinating polyneuropathy or myositis: treatment with plasmapheresis and immunosuppressive drugs

Four patients with chronic, progressive demyelinating peripheral polyneuropathy were found to have paraproteinemia. Two of the patients had multiple myeloma [both immunoglobulin (Ig)G lambda]. The other two had benign gammopathies: one of IgG kappa type and the other one with marked polyclonal elevation of IgM. Immunofluorescence studies revealed deposits of the abnormal serum immunoglobulin along the myelin sheaths in two of the patients in whom sural nerve biopsies were performed. All four patients were treated with plasmapheresis in combination with immunosuppressive drugs. Favorable responses to the therapy was observed in all four patients, but the degree of response varied from patient to patient. Two patients who presented clinical and electromyographic findings consistent with polymyositis were found to have serum IgG kappa M components. Immunofluorescence studies performed on muscle biopsy material from both patients revealed deposits of the abnormal serum paraprotein along the sarcolemmal basement membrane. A treatment course of plasmapheresis and immunosuppressive drugs resulted in a sustained increase of muscle strength in both patients.

Ocular palsy preceding chronic relapsing polyneuropathy by several weeks

Three patients exhibited an unusual variant of chronic relapsing polyneuritis in which extraocular muscle palsies developed 19 days, 20 days, and 3 1/2 months, respectively, before the neuropathy affected the limbs. The peripheral neuropathy evolved over 7 to 12 weeks, lasted 15 months to 13 years, and relapsed in every case. Each patient had dysphagia, areflexia, sensory loss, and weakness of all four limbs, which in two was asymmetrical. Slowed motor nerve conduction and prolonged F wave latencies were present, and the cerebrospinal fluid protein level was elevated without increased cell count. No patient recovered fully despite treatment with immunosuppressant drugs.

Chronic inflammatory polyneuropathy. Reduction of nerve conduction velocities in monkeys by systemic passive transfer of immunoglobulin G

In chronic (relapsing) inflammatory polyneuropathy (CRIP), successful treatment with plasma exchange has led to the concept of pathogenic humoral factors. In 6 patients with CRIP, 5 of whom improved after plasma exchange, the potential pathogenic role of circulating immunoglobulin (Ig) fractions was tested by applying the systemic passive transfer model to marmoset monkeys. After continuous treatment with intramuscular injections for 2-8 weeks, monkeys injected with the crude immunoglobulin fractions or with purified IgG from 5 of the 6 patients showed a significant and partially reversible reduction of the motor nerve conduction velocity (mean 34%, P less than 0.001) when compared with pre-treatment values. In control animals the reduction was 4%. Morphological examination revealed only minor ultrastructural changes of the myelin sheath. Immunocytochemistry revealed that human IgG was able to cross the blood-nerve barrier. It is concluded that the circulating IgG-fraction of patients with CRIP contains a factor that may contribute to the disordered nerve function after crossing the blood-nerve barrier. It may be the removal of this particular factor which is responsible for the rapid recovery of nerve conduction in patients after plasma exchange.

Neuropathological findings in Miller Fisher syndrome

The neuropathological findings in a fatal case of Miller Fisher syndrome are described. The demyelinating peripheral neuropathy and normal appearance of the central nervous system that were observed support the inclusion of the syndrome within the spectrum of acute inflammatory polyneuropathy.

Chronic polyneuropathy of undetermined cause

The case histories of 519 patients with peripheral neuropathy on whom sural nerve biopsy had been performed were reviewed. In 67 patients (50 males, 17 females) (13%) who had symptoms of a symmetrical polyneuropathy for more than one year, the cause remained undiagnosed in spite of intensive investigation. Patients with inflammatory neuropathy were not included, but represented 17% of the whole series. The mean age of onset of symptoms was 50.6 years, and the median time from onset of symptoms to initial investigation was 2 years. Males were affected more commonly than females in a ratio of 3:1. The clinical features in 43 patients were those of a mixed motor and sensory neuropathy, in 17 patients a predominantly sensory neuropathy and in 7 patients a predominantly motor neuropathy. The mean CSF protein was 0.73 g/l and in only six patients was it greater than 1 g/l. Nerve conduction studies most commonly demonstrated mild slowing of motor conduction and impairment of sensory conduction. The usual pathological changes on sural nerve biopsy were those of chronic axonal degeneration. Forty seven patients (70%) were re-examined at intervals of time which ranged from 4 months to 12 years after their initial presentation and nerve biopsy (median, 3 years). As a group, they were only mildly disabled, the condition had a very slowly progressive course and there had been little change in their disability. A possible aetiological factor was found in 17 of the 47 patients (36%) and included malignancy, alcoholism, and benign paraproteinaemia. It is concluded that with intensive investigation the cause of chronic polyneuropathy of duration greater than one year remains undetermined in only about 13% of patients and that continued follow-up is worthwhile since a diagnosis may be established on re-examination.

Demyelination induced by serum from patients with Guillain-Barré syndrome

Sera from 16 patients with acute Guillain-Barré syndrome (GBS) and 14 healthy control subjects were injected into rat sciatic nerve and assessed for demyelinating activity by electrophysiological and histological techniques. Only fresh GBS serum, and not GBS serum stored at -20 degrees C or -70 degrees C, blocked conduction to a significantly greater extent than did fresh control serum. Conduction block developed gradually, starting within 24 hours of injection and reaching a maximum between days 3 and 6. Recovery of conduction commenced thereafter, and conduction returned to normal by day 33. Quantitative histological studies on day 6 showed that fresh GBS serum produced significantly more widespread demyelination than did stored GBS serum (p less than 0.01). Stored GBS serum showed residual demyelinating activity when compared with fresh control serum (p less than 0.01). Fresh serum obtained from 4 patients after recovery from GBS did not produce conduction block, despite it having done so during the acute phase of the disease.

Polyneuropathy in nonmalignant IgM plasma cell dyscrasia: a morphological study

Six patients had peripheral neuropathy and nonmalignant IgM plasma cell dyscrasia. In two of them, immunological studies indicated that the monoclonal immunoglobulin reacted with myelin-associated glycoprotein, a constituent of peripheral nerve myelin. Sural nerve biopsy specimens from both patients showed morphological signs of primary damage to the myelin sheath. In the other four patients, two of whom had a monoclonal IgMK reactive with chondroitin sulfate C, the axon rather than the myelin sheath was considered the chief site of nerve injury. The morphological findings suggest that the pathogenesis of peripheral neuropathies in IgM plasma cell dyscrasia is heterogeneous. Moreover, the observations are consistent with a pathogenic interaction of the IgM paraprotein with autoantigens in peripheral nerve in some instances.

[Recurrent polyradiculoneuritis: report of 2 cases]

Two cases of patients with relapsing polyradiculoneuropathy with high protein level in cerebrospinal fluid are reported. The immunological features and the natural history of the relapsing polyradiculoneuropathy are discussed. This disease is considered a particular auto-immune nosologic condition, independent from acute polyradiculoneuropathy.

Multiple sclerosis and hypertrophic demyelinating peripheral neuropathy

A combination of multiple sclerosis (MS) and hypertrophic demyelinating neuropathy has been reported in a few autopsy studies. We are reporting a unique case of such a combination, which was proved by the sural nerve biopsy. A patient with classical MS on history and findings had areflexia and sensory abnormalities in stocking distribution. The nerve conduction study showed marked abnormalities indicative of demyelinating neuropathy, and sural nerve biopsy was typical of hypertrophic demyelinating neuropathy.

Prediction of response to plasma exchange in chronic relapsing polyneuropathy. A clinico-pathological correlation

The clinical features, results of nerve conduction studies and sural nerve biopsy findings have been compared in 5 patients with chronic relapsing polyneuropathy in whom plasma exchange was used in treatment. In 2 patients who consistently responded to plasma exchange, the dominant pathological findings was segmental demyelination without prominent onion bulb formation, whereas axonal degeneration was more prominent in the cases which did not respond. It is concluded that in cases of chronic relapsing polyneuritis where the clinical, electrophysiological and histological features suggest primary demyelination, plasma exchange may provide a useful adjunct to therapy.

Polyneuropathy and benign monoclonal gammopathy

Recently the rather frequent occurrence of benign monoclonal gammopathy (BMG) has been reported in peripheral neuropathy. Sometimes this syndrome is part of a multisystemic disorder in which organomegaly, endocrine disturbances, skin changes and focal bone lesions may also occur. The clinical picture and the cerebro-spinal fluid findings resemble the chronic relapsing Guillain-Barré syndrome. The polyneuropathy seems to be of the primarily demyelinating type. The pathogenetic relationship with the gammopathy is as yet not clear, but treatment of the plasma cell dyscrasia has a favourable effect on the polyneuropathy. We report our experiences with 5 patients with polyneuropathy and BMG and compare our clinical, laboratory and histological data with the literature.

A clinical study of the Guillain-Barré Syndrome

60 consecutive patients (age 15-77 years) with the Guillain-Barré syndrome were studied. 37 subjects had an antecedent infection. Onset occurred with motor and/or sensory limb symptoms in 56 cases; 4 subjects experienced onsets with pain, diplopia or bladder disturbances. The motor symptoms reached a maximum within 42 days in all cases, 87% within less than 20 days. All patients had limb-muscle weakness at the symptomatic maximum: 50% exhibited cranial-nerve affections and 10 subjects has respiratory insufficiency. Signs of a remission appeared within 60 days after onset in all cases surviving the maximal phase, 81% within less than 40 days. The CSF protein concentration was elevated (0.6-7.8 g/l) in 95% of the patients; an increased mononuclear cells count 6-60 X 10(6)/l) occurred in 27% of cases. Electrophysiological abnormalities were detected in 42 out of 43 examined cases. Totally there were 4 deaths, all caused by cardiac or thrombo-embolic events. Surviving patients had restitutions without functionally significant sequelae within less than 6 months after onset in 73% of cases; all but 2 of the remaining patients recovered within 18 months. The degree of muscle weakness at maximum was the predominant prognostic factor.

Late onset of Guillain-Barré syndrome

The Guillain-Barré syndrome (GBS) usually occurs within one month of the precipitating cause. It is the purpose of this paper to show that typical cases may, however, appear weeks to months later. We have reviewed the collected data on these cases and suggest that they provide evidence which is in favour of a humoral, rather than a cell-mediated, aetiology for GBS.

An infant with chronic, relapsing polyneuropathy responsive to steroids

A seven-week-old infant presented with an acute flaccid paraparesis. Her subsequent course was punctuated by numerous exacerbations, in association with minor intercurrent illness and remissions produced by corticosteroid treatment. Postmortem examination revealed a chronic inflammatory polyradiculopathy. She represents the youngest patient yet described with a chronic, relapsing, steroid-responsive polyneuropathy.

Plasma exchange in chronic inflammatory polyneuropathy: evidence suggestive of a pathogenic humoral factor

Chronic progressive of relapsing inflammatory polyneuropathy (CRIP) can be treated effectively with immunosuppressive drugs and/or plasma exchange (PE). This report describes a patient who responded dramatically and reproducibly to PE during four successive relapses and remained in remission while on medical immunosuppression with azathioprine and corticosteroids. The clinical course was closely correlated with electrophysiologic parameters such as compound muscle action potential amplitudes and distal latencies. The purified IgG fraction of PE filtrate bound to rat and human sciatic nerve on immunohistochemistry. Furthermore, a similar staining pattern was achieved by purified Fab fragments, which was absent in all control preparations. These findings support the hypothesis that circulating plasma factors may play a role in CRIP and that one of these factors may be an IgG antibody to peripheral nerve components.

Specificity of plasmapheresis in the treatment of chronic relapsing polyneuropathy

A 27-year-old woman with an eight year history of chronic relapsing polyneuropathy presented in her fifth relapse. Raised immune complexes prompted a trial of plasmapheresis. Remarkable clinical improvement was seen after the second exchange. Complete remission was obtained after ten treatments. Subsequently, further relapses have occurred, each responsive to plasmapheresis. The effect of plasma exchange in this patient appears to be unique as neither charcoal perfusion nor plasma infusion per se proved efficacious. The patient is currently maintained with weekly plasma exchanges, her course complicated by supervening hepatitis B antigenemia. The clearance of immune complexes observed during plasmapheresis raises the possibility that removal of a serum factor is responsible for her clinical improvement and that patients with such a factor may benefit from plasmapheresis.

Chronic relapsing polyneuropathy associated with immunoblastic lymphadenopathy

Two episodes of severe, relapsing sensorimotor polyneuropathy closely paralleled the course of systemic illness in a patient with immunoblastic lymphadenopathy. A review of the literature shows three other cases, although none with documented pathologic changes in muscles and nerves. Based on the pathologic findings in this patient, the peripheral neuropathy associated with immunoblastic lymphadenopathy can be classified under the group of relapsing inflammatory polyneuropathies associated with systemic disorders. Whether prednisone therapy helped this condition is uncertain.

Childhood chronic relapsing polyneuropathy: dramatic improvement following plasmapheresis

We present clinical data on two boys with chronic relapsing polyneuropathy. Their recurrent episodes of weakness had produced marked disability which was unresponsive to continuous prednisone therapy. Plasmapheresis produced dramatic improvement in muscle strength and functional ability. The remissions induced have been sustained despite withdrawal of steroid therapy.

In vivo demyelinating activity of sera from patients with Guillain-Barré syndrome

The in vivo demyelinating capacity of sera from 27 patients with Guillain-Barré syndrome (GBS) and 47 other individuals was studied by intraneural injection into rat sciatic nerves. The morphological features of the nerves in cross section taken just proximal to the site of needle insertion was assessed 48 hours after injection and the extent of demyelination was quantitated. All 27 GBS serum samples were obtained in the first three weeks of clinical disease. Of these, 11 (41%) produced demyelination. Demyelinative activity of GBS sera correlated only with severity of clinical disease (p less than 0.01). The extent of demyelination after intraneural injection of human sera was less intense on average than that produced by sera from animals with experimental allergic neuritis. Three of 40 (7.5%) sera obtained from normal subjects and patients with other neurological diseases also caused in vivo demyelination, although the activity was weaker and occurred less often than with GBS serum.

Chronic relapsing polyneuritis. A light- and electron-microscopic study

The clinico-pathologic findings in two patients with chronic relapsing polyneuritis are reported. The patients had several attacks of diffuse polyneuritis followed by partial recovery. The tendency to persisting disability increased following relapses and in the late stages there was a progressive motor deterioration suggesting a continuing activity of nerve damage. The biopsies of peripheral nerves, obtained in the advanced stages of the disease, showed severe loss of myelinated fibers and aspects of repeated demyelination and remyelination, with formation of onion bulb complexes. Completely demyelinated axons together with remyelinating fibers as well as remyelinated fibers invested by macrophages were seen at the same time. The clinical and pathological evidences suggest that in chronic relapsing polyneuritis, at least in the late stages of the disease, besides clinical relapses, there is a continuing activity of nerve damage. Thus, due to this ongoing activity of demyelination and remyelination, the elimination of the supernumerary Schwann cells does not take place satisfactorily and hypertrophic changes of the nerve fascicles are produced.

Criteria for the diagnosis of the Guillain-Barré syndrome. A critique of the NINCDS guidelines

The publication of "official" criteria for the diagnosis of the Guillain-Barré syndrome designed for the purpose of aiding epidemiological studies, has resulted in excluding from consideration a number of fragmentary and atypical cases. Because it is a syndrome and not a disease entity, the limits are arbitrary. Several of the criteria are confusing and contradictory; they ignore a vast amount of literature which clearly documents the variability of the signs and symptoms.

Acute inflammatory polyradiculoneuropathy following type A viral hepatitis

A case is described of acute inflammatory polyradiculoneuropathy (Guillain-Barré syndrome) following a recent infection with type A viral hepatitis. This association has not previously been reported. The neurological disturbance was unusual in being predominantly sensory.

Immunological characterization of sural nerve biopsies from patients with Guillain-Barré syndrome

Among eight sural nerve biopsies from patients with the Guillain-Barré syndrome (GBS), demyelination was observed in five and endoneural mononuclear cell infiltrates in three. Receptors for the activated third component of complement (C3b) were detected within the nerve fascicles. The receptor activity was reduced in five biopsies, and in vivo deposition of C3 within the endoneurium occurred in four. Immunoglobulins were found in four biopsies and appeared to be localized along the myelin sheaths. Both T and B lymphocytes could be detected in the mononuclear cell infiltrates, but the relative proportions of these cells could not be determined. Macrophages present in two biopsies were found to possess IgG Fc receptors. The results indicate that the complement receptors may play a role in the binding of complement-containing complexes in the nerve during the GBS disease process.

Diagnostic considerations in Guillain-Barré syndrome

Guillain-Barré syndrome (GBS) is a recognized entity for which the basis for diagnosis is descriptive in our present state of knowledge. Diagnosis rests upon pattern recognition of the clinical picture plus other features including elevated cerebrospinal fluid protein level, electrophysiological changes of marked slowing of conduction velocities, prolonged distal latencies, dispersion of the evoked responses, and frequent evidence of conduction block, together with pathological changes, when known, of low grade-inflammation and demyelination-remyelination in peripheral nerve. The precise diagnostic limits of GBS remain uncertain.

Chronic relapsing (dysimmune) polyneuropathy: pathogenesis and treatment

Chronic relapsing polyneuropathy is a distinct dysschwannian/demyelinating polyneuropathy characterized by usually slow onset, progressive or relapsing-remitting course, elevated cerebrospinal fluid (CSF) protein, marked slowing of nerve conduction velocity, segmental demyelination demonstrable in sural nerve biopsies, and absence of systemic illness or abnormal serum immunoglobulins. The cause of the disorder and the mechanisms underlying its chronicity and relapsing-remitting course are not clear. Immunoglobulin deposition observed in sural nerve biopsies and abnormal immunoglobulin patterns in the "CSF in some cases suggest a dysimmune pathogenesis; thus the term chronic relapsing (dysimmune) polyneuropathy (CRDP) is preferred. The disease is a treatable form of idiopathic polyneuropathy. In our series of 25 patients with CRDP, treatment with high-single-dose daily prednisone, slowly tapered to an alternate-day program, has been very successful in the majority. A low (10 to 20 mg) alternate-day-single-dose program, maintained indefinitely, seems to be required to prevent future recurrences. Evidence is provided that other immunosuppressants (azathioprine, cyclophosphamide, poly-ICLC) and possibly plasmapheresis, alone or in conjunction with corticosteroids, may have a beneficial role in controlling difficult cases of chronic relapsing polyneuropathy.

Treatment of acute inflammatory polyneuropathy

Most patients with acute inflammatory polyneuropathy (AIP) recover spontaneously, but the time course of the illness is unpredictable so that the results of treatment are difficult to assess. Three decades of retrospective reports of steroid treatment fail to demonstrate any striking beneficial effect. In a randomized trial of prednisolone, starting dose 60 mg daily, 21 treated patients improved more slowly than 19 untreated patients. By contrast, in rats immunized with bovine nerve root myelin, prednisolone at 10 mg/kg reduced the severity and duration of experimental allergic neuritis (EAN), the putative animal model for AIP. This discrepancy might reflect the greater difficulty of clinical as opposed to animal therapeutic trials or indicate that EAN is not the appropriate model for the human disease. Immunosuppressive drugs, plasmapheresis and other agents have also been employed, but their efficacy cannot be decided from the available case report. The role of similar agents in chronic progressive and relapsing inflammatory neuropathy cannot yet be resolved, but in some patients steroids do appear to be valuable.

the role of autoantibody and immune complexes in the pathogenesis of Guillain-Barré syndrome

Evidence that Guillain-Barré syndrome (GBS) may be caused, at least in part, by antibodies to nerve tissue or soluble immune complexes is reviewed. Although insufficient proof exists at present to confirm a causal relationship between humoral factors and GBS, converging lines of evidence support this possibility.

Electrophysiological studies in the Guillain-Barré syndrome

Electrophysiological studies were performed on 114 patients with Guillain-Barré syndrome and the literature was reviewed. Abnormalities of motor and sensory conduction were present in about 90% of the patients. Because of the patchy distribution of demyelinating lesions, the likelihood of detecting electrophysiological abnormalities increases with the number of nerves studied. Marked slowing of conduction or an abnormally prolonged distal motor latency consistent with demyelination was found in one or more nerves in about 50% of the patients. Abnormalities of conduction not present in the early stages of the illness may become evident at the peak of disability or during the recovery phase. The application of F-wave studies and somatosensory evoked potential recordings may assist in detecting demyelination in roots and proximal segments of the peripheral nervous system. There is no correlation between the degree of slowing of conduction and the duration of illness or the long-term prognosis. Abnormalities of conduction at follow-up do not correlate with the clinical disability. On the other hand, electromyographic findings of abundant spontaneous fibrillation and other evidence of axonal degeneration are associated with a poor prognosis for complete recovery and also with a slower rate of recovery from the initial illness.

Pathology of the Guillain-Barré syndrome

The Guillain-Barré syndrome is a distinctive neuropathy characterized pathologically by the presence of inflammatory lesions which occur scattered throughout the peripheral nervous system. The lesions consist of circumscribed areas in which myelin is lost in the presence of lymphocytes and macrophages. Myelin damage of effected largely by macrophages, which penetrate the basement membrane around nerve fibers and strip what appears to be normal myelin away from the body of the Schwann cell and off the axon. While there is evidence that this activity is immune mediated, the precise mechanism that leads macrophages to seek out and amputate a specialized region of the Schwann cell plasma membrane remains unexplained.

Experimental allergic neuritis induced by galactocerebroside

Experimental allergic neuritis (EAN), an animal model of human demyelinative neuritis, was induced by sensitization with galactocerebroside, a glycolipid hapten common in central and peripheral nervous system myelin. Between two months and one year after the initial sensitization, 11 of 24 rabbits immunized repeatedly with bovine brain galactocerebroside (GC) in complete Freund's adjuvant developed a neurological disorder manifested by flaccid quadriparesis, limb hypesthesia, and respiratory paralysis. Seventeen of 20 autopsied rabbits, including all those with clinical illness, had small multiple perivascular foci of demyelinative lesions in roots, dorsal root ganglia, proximal peripheral nerves adjacent to ganglia, and, less frequently, in distal nerves. No change was found in the central nervous system. Demyelination started around venules, with splitting and vesiculation of the outer myelin sheaths of adjacent fibers, and later progressed to form confluent lesions. The lesions were associated with infiltration of phagocytic mononuclear cells, mostly macrophages, which insinuated themselves between myelin lamellae, phagocytized myelin, and subsequently denuded axons. Perivenular infiltration of small lymphocytes, comparable to that seen in whole nerve- induced EAN, was not encountered. The distribution of demyelinative lesions seems to correspond to areas known to have a defective blood-nerve barrier.

Steroid-responsive polyneuropathy with subacute onset in childhood

Five pediatric patients with subacute onset polyneuropathy are presented, with electrophysiologic and pathologic data. All patients improved, the majority to resolution, with administration of prednisone. Distinguishing factors included (1) subacute onset polyneuropathy progressing gradually over weeks to months, (2) primarily motor neuropathy with little cranial nerve involvement, (3) elevated CSF protein concentration, (4) markedly delayed nerve conduction velocities, and (5) tendency toward relapse and recurrence. Although this disorder may share characteristics with the Guillain-Barré syndrome, its steroid responsiveness sets it apart clinically from the acute form of the disease. Because of the steroid responsiveness, it is important to recognize this entity.

Antiserum-mediated demyelination: relationship between remyelination and functional recovery

A focal demyelinative lesion of peripheral nerve was produced by intraneural injection of either antiserum from rabbits with experimental allergic neuritis or experimental allergic encephalomyelitis or antiserum to galactocerebroside. We studied the relationship between clinical and electrophysiological recovery from this lesion and the morphological pattern of remyelination. Foot muscles on the the injected side weakened within an hour of injection and remained paralyzed for 7 days; strength gradually returned to normal by 16 days after injection. Electrophysiological conduction block, apparent within a few hours of injection, persisted for about 7 days. At 8 days we detected dispersed, very low amplitude muscle action potentials with long latency. Morphologically, demyelinated axons were surrounded by Schwann cells at 7 days after injection, but compacted myelin was not present. After 8 days, remyelinating axons became surrounded by thickening compacted myelin. The time of onset of remyelination and the rate of remyelination up to 14 days following the injection were independent of axon size. The onset of clinical and electrophysiological recovery from the lesion corresponded to the appearance of 2 to 8 myelin lamellae around each remyelinating axon. At 37 days after injection, when conduction velocities had returned to preinjection values, myelin thickness of remyelinating fibers had increased to approximately one-third that of control nerves.