Immunological parameters in Guillain-Barré syndrome

[Guillain-Barré syndrome after exposure to influenza]

Guillain-Barré Syndrome (GBS) is an acquired, monophasic inflammatory polyradiculoneuritis of autoimmune origin, which occurs after infection and occasionally also after vaccination. Seasonal and pandemic influenza vaccines have in particular been implicated as triggers for GBS. However, a number of recent studies indicate that infection with influenza virus may also cause GBS. This review summarizes the epidemiological and experimental data of the association of GBS with exposure to influenza antigens by immunization (including vaccines against A/H1N1/2009) and infection. Vaccination against influenza is associated with a very low risk for the occurrence of GBS. In contrast infection with influenza may play a more important role as a triggering factor for GBS than previously assumed.

Guillain-Barré syndrome after exposure to influenza virus

Guillain-Barré syndrome (GBS) is an acute, acquired, monophasic autoimmune disorder of peripheral nerves that develops in susceptible individuals after infection and, in rare cases, after immunisation. Exposure to influenza via infection or vaccination has been associated with GBS. We review the relation between GBS and these routes of exposure. Epidemiological studies have shown that, except for the 1976 US national immunisation programme against swine-origin influenza A H1N1 subtype A/NJ/76, influenza vaccine has probably not caused GBS or, if it has, rates have been extremely low (less than one case per million vaccine recipients). By contrast, influenza-like illnesses seem to be relevant triggering events for GBS. The concerns about the risk of inducing GBS in mass immunisation programmes against H1N1 2009 do not, therefore, seem justified by the available epidemiological data. However, the experiences from the 1976 swine flu vaccination programme emphasise the importance for active and passive surveillance to monitor vaccine safety.

Miller Fisher syndrome and Escherichia coli infection: is it a novel association?

Miller Fisher syndrome is characterized by ataxia, ophthalmoplegia, and reduced or absent tendon reflexes. Generally, it is considered an acute postinfectious paralytic illness caused by a wide variety of infections including Campylobacter jejuni. The authors report the case of a 10-year-old girl with Miller Fisher syndrome who had a previous infection of Escherichia coli. If confirmed by other reports, this report could disclose a new association of Miller Fisher syndrome with E coli infection.

Current Therapeutic Options in Severe Guillain-Barre?? Syndrome

The classical form of Guillain-Barré syndrome (GBS) refers to an acute monophasic demyelinating motor and sensory polyneuropathy characterized by symmetric ascending flaccid weakness, along with sensory impairment and, less commonly, autonomic perturbations. Pure motor axonal forms, axonal motor, and sensory forms, as well as pure autonomic forms, have also been identified. A complex immune-mediated process leads to segmental demyelination accompanied with axonal involvement in protracted cases. Establishing strategies of immunomodulation may therefore halt and even reverse the harmful autoimmune insult to peripheral nerves. The present article reviews the current immunomodulatory options in severe GBS. A recent Cochrane meta-analysis of 6 randomized studies showed no significant improvement using corticosteroids, including either oral or intravenous methylprednisolone. Combined methylprednisolone and immunoglobulins shortened the time lapse to regain independent walking. Plasmapheresis (PE) was the first effectively proven method of immunomodulation, followed by intravenous immunoglobulins (IVIG). Both methods are comparable in their beneficial effect and were used either separately or in combination, but PE was more frequently associated with severe adverse effects requiring cessation of therapy, including a bleeding diathesis. In addition, PE is feasible only in major referral centers requiring the appropriate equipment and trained personnel. In addition, younger children may be at risk for bleeding after insertion of wide catheters. Therefore, in cases of severe GBS, IVIG is recommended as the first-line drug using a total empiric dose of 2 g/kg administered over 2 consecutive days, especially in children proven highly effective with negligible adverse effects. In protracted cases, the addition of intravenous corticosteroids to IVIG should be considered, which may shorten the duration to regain independent walking. If such therapy fails, PE should be applied using centrifugal blood separators with 5% albumin as the substitute solution.

Outcome of severe Guillain-Barré syndrome in children: comparison between untreated cases versus gamma-globulin therapy

The objective of this study was to assess retrospectively the outcome of children with severe Guillain-Barré syndrome (GBS) treated either with intravenous immunoglobulins (IVIG) versus practically untreated cases by a known beneficial agent. Twenty-three children with severe GBS who became bedridden (i.e., Motor Disability Grading Scale [MDGS] grade of at least 4) were analyzed. Fifteen children were treated with IVIG and eight children comprised the nontreatment group: five on supportive therapy and three treated previously with oral steroids found ineffective in GBS. IVIG was administered at a dosage of 1 g/kg daily for 2 days under constant monitoring, with no adverse effects requiring cessation of therapy. Improvement by 1 grade on the MDGS after IVIG therapy was achieved in the IVIG group after a mean of 10.17 days (median, 8 days), and patients started walking independently after a mean of 30.35 days (median, 20.5 days). Improvement by 1 grade on the MDGS was achieved in the nontreatment group after a mean of 22.3 days (median, 20.3 days), and they started to walk independently after a mean of 113.3 days (median, 100 days). A significant difference could not be delineated between both groups, given the rather small number of children in each group. These results indicate a possible beneficial effect of IVIG in severe childhood-onset GBS compared with the nontreated group of children. The authors therefore recommend using IVIG as the first-line drug in such cases, which warrant further approval after double-blind controlled studies of using different IVIG regimens or combined with plasmapheresis and steroids.

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.

Anti-GM1, anti-central myelin proteins, and anti-cardiolipin autoantibodies during plasma-exchange in Guillain-Barré syndrome (GBS)

We measured the autoantibodies to GM1, central myelin proteins, and cardiolipin in 30 GBS patients using sensitive ELISA and Western blot techniques. The sequential modifications of titers during plasma-exchange (PE) and at follow-up were investigated in 15 patients. In pretreatment sera, we found significantly increased antibody titers to GM1 (37% of the patients), central myelin proteins (28%), and cardiolipin (21%). Seventeen patients out of 29 (58%) presented increased IgG or IgM antibody to at least one of the antigens considered as compared to 10 out of 70 controls (14%, P = 0.00001). By Western blot, IgG or IgM antibodies reactive with the triton insoluble fraction of central myelin were observed in 19 out of 28 GBS patients (67%). The follow-up measurements during and after PE showed a declining autoantibody titer in 10 out of 15 patients. However, in the remaining 5 GBS patients, we observed a persistently elevated titer or an increase from baseline values occurring during or after PE and reaching a peak. In 2 of the 5 patients, the titer peak preceded a clinical re-exacerbation. The presence of a persistently elevated or an increasing autoantibody titer during treatment with PE merits further investigation and may help to clarify the pathogenesis of GBS and improve its treatment.

New concepts of Guillain-Barré syndrome

Guillain-Barré syndrome is an acute autoimmune polyradiculoneuropathy with a clinical presentation of flaccid paralysis with areflexia, variable sensory disturbance, and elevated cerebrospinal fluid protein without pleocytosis. Although Guillain-Barré syndrome previously had been viewed as a unitary disorder with variations, it currently is viewed as a group of syndromes with several distinctive subtypes. These include the principal subtype prevalent in the Western world (acute inflammatory demyelinating polyradiculoneuropathy, and others, each with distinctive electrodiagnostic and pathologic features, including acute motor axonal neuropathy), acute motor-sensory axonal neuropathy, Miller Fisher syndrome, and perhaps others. The clinical and pathologic features of these Guillain-Barré syndrome subtypes are reviewed, and the role of antecedent infections, particularly Campylobacter jejuni gastroenteritis, and the role of antiganglioside antibody responses are reviewed with respect to pathogenesis. Treatment of Guillain-Barré syndrome includes both important supportive measures and immunotherapies, specifically high-dose intravenous immunoglobulin and plasma exchange.

The immunopathogenesis of Miller Fisher syndrome

Over the past decade, remarkable progress has been made in our understanding of the pathogenesis of Miller Fisher syndrome (MFS), a clinical variant of Guillain Barré syndrome (GBS). MFS comprises the clinical triad of ataxia, areflexia and ophthalmoplegia. It is associated with acute-phase IgG antibodies to GQ1b and GT1a gangliosides in over 90% of cases which are highly disease specific. Like GBS, MFS is a post-infectious syndrome following diverse infections, but particular attention has been paid to its association with Campylobacter jejuni enteritis. Serostrains of C. jejuni isolated from infected patients bear ganglioside-like epitopes in their lipopolysaccharide core oligosaccharides, which elicit humoral immune responses exhibiting molecular mimicry with GQ1b/GT1a gangliosides. These antibodies are believed to be the principal cause of the syndrome and physiological studies aimed at proving this have focused on the motor-nerve terminal as a potential site of pathogenic action. This review describes these findings and formulates a pathogenesis model based on our current state of knowledge.

Intravenous immunoglobulin in very severe childhood Guillain-Barré syndrome

To evaluate intravenous immunoglobulin (IVIG) therapy in children with very severe Guilain-Barré syndrome (GBS) with reference to the need for respiratory support, ICU stay and long-term outcome, we studied 33 children with very severe GBS and quadriparesis and/or respiratory muscle weakness admitted to the Pediatric Intensive Care Unit (PICU) of PGIMER, Chandigarh. Cases (n = 22, IVIG group) were enrolled prospectively, and controls (n = 11), similar to cases in age and severity of illness, retrospectively. All children received similar supportive and respiratory care. In addition, cases were given IVIG (Sandoglobulin, Sandoz) 0.4 g/kg bodyweight per day for 5 days. The mean age, duration of symptoms prior to admission and severity of illness in the two groups were similar. In the IVIG group, onset of recovery of muscle power was significantly earlier (day 14.8 (6.8) of illness vs day 20.9 (8.6), p < 0.05) and the length of PICU stay significantly shorter (20.5 (13.0) days vs 50.5 (33.3) days, p < 0.01). Sixteen (72.7%) children in the IVIG group had improved by at least one functional grade after 1 month and 15 (68%) were walking independently after 3 months compared with two (18%) and four (36%) controls, respectively (p < 0.05). The number of children who needed endotracheal intubation and mechanical ventilation and the duration of mechanical ventilation was significantly less in the IVIG-treated group. We conclude that in very severe GBS in children IVIG therapy improves outcome to a remarkable extent, reduces the need for intubation and mechanical ventilation, shortens the length of stay in ICU, and promotes ambulation sooner.

Pathogenesis of neuroimmunologic diseases. Experimental models

Animal models of autoimmune diseases have greatly improved our current understanding of the pathogenesis of human autoimmunity and have provided the potential for therapies based on manipulation of the immune system. In our laboratory, we have investigated the immunopathogenesis of autoimmune diseases of the nervous system and muscle. We have developed immune-based approaches for the suppression of experimental autoimmune encephalomyelitis (EAE), a model for multiple sclerosis (MS), and experimental autoimmune neuritis (EAN), a model for the Guillain-Barré syndrome (GBS). These approaches included induction of peripheral tolerance, immunotoxin targeting of activated T cells, and cytokine manipulations. In addition, we identified the antigen and characterized immunopathologically an autoimmune inflammatory disease of skeletal muscle, experimental autoimmune myositis (EAM), a model for the human inflammatory muscle disease polymyositis.

Magnetic resonance imaging of the cauda equina in two patients with Guillain-Barré syndrome

The results are presented of magnetic resonance imaging (MRI) of the spine in two cases of childhood Guillain-Barré syndrome. After injection of gadolinium-diethylenetriamine pentaacetic acid, MRI showed enhancement of the cauda equina in these patients. These MRI observations may help confirm the diagnosis of Guillain-Barré syndrome. The nerve root enhancement resolved as the clinical symptoms improved. Serial imaging may be useful in monitoring the response to therapy and assessing new treatment regimens. It may also yield a better understanding of the disease process.

Rehabilitation of Guillain-Barré syndrome

Guillain-Barré syndrome (GBS) is the most common cause of acute neuromuscular paralysis in developed countries. GBS is a significant cause of new long-term disability for at least 1,000 persons per year in the United States, and more elsewhere. Given the young age at which GBS sometimes occurs and the relatively long life expectancies following GBS, it is likely that at least 25,000 and perhaps 50,000 persons in the US are experiencing some residual effects of GBS. Approximately 40% of patients who are hospitalized with GBS will require admission to inpatient rehabilitation. For GBS persons necessitating admission to inpatient rehabilitation, the requirement of prior ventilator support most strongly predicts an extended length of stay on inpatient rehabilitation. Other issues that affect rehabilitation are dysautonomia, cranial nerve involvement, and various medical complications associated with GBS. Deafferent pain syndrome is common in the early stages of recovery. Multiple medical complications, including deep venous thrombosis, joint contractures, hypercalcemia of immobilization, and decubitii, may develop in the early stages of recovery and interfere with the rehabilitation program. Anemia is a frequent finding in the first few months of illness but does not appear to interfere with functional recovery. Therapy should not overfatigue the motor unit, which has been associated with paradoxical weakening. Little is known of the long-term implications of the disability caused by GBS. Work similar to that performed for postpolio syndrome and spinal cord injury should be started in the rehabilitation setting.

Guillain-Barré syndrome in Stockholm County, 1973-1991

In order to describe the incidence of Guillain-Barré syndrome (GBS) in Stockholm County (SC) and hospital use by GBS patients, we conducted a retrospective epidemiological study on GBS covering 1973-1991, using the Hospital Inpatient Register in SC. There were 556 patients, bona fide residents in the county during the study period, discharged from hospitals with GBS diagnosis. The mean annual incidence, age-adjusted to the European population, was 1.84 (2.15 for males and 1.57 for females) per 100,000 population. The incidence increased with age and showed a bimodal distribution with peaks in the 10-29 and 70-79 age-groups. Annual incidence rates were highest in 1978 and 1983. Neither heterogeneity of annual or monthly rates nor linear trends during the period were found to be significant, except in 1978 for patients below 40 years of age, RR 1.72 (95% CI 1.08-2.71) and in 1983 for patients at ages 40 years and over, RR 1.48 (95% CI 1.02-2.16), when compared with GBS incidences in the same age-groups during the remaining study period. The mean +/- SD duration of hospital stay, including long-term care or rehabilitation institutions, for GBS patients, was 86 +/- 210 days, with considerably longer duration for the elderly. The rate of hospital use by GBS patients was 162 days per 100,000 inhabitants per year. In accordance with results of prior studies in South-West Stockholm and described GBS epidemics in Sweden, this study supports that an etiologically different subgroup of GBS exists at ages below 40 years, and that relevant but small time-space variations, such as the reported zimeldine epidemic in 1983, resist detection by hospital data analysis of pooled GBS cases. Efficient epidemiological surveillance of GBS may require targeted development of clinico-epidemiological tools.

Immune globulins are effective in severe pediatric Guillain-Barré syndrome

The effect of high-dose intravenous immune globulins was evaluated in an open prospective multicenter study of 26 children with severe Guillain-Barré syndrome. They presented with mild to moderate flaccid weakness of extremities, with cranial nerve involvement (20) and sensory impairment (22). All children rapidly deteriorated in 2-16 days (mean 6) to become bedridden, and 2 children also developed respiratory failure requiring artificial ventilation (Disability Grading Scale 4-5). Immune globulins were then administered at a total dose of 2 gm/kg, on 2 consecutive days, without adverse effects requiring discontinuation of therapy. Marked and rapid improvement was noted in 25 children, who improved by 1 to 2 Disability Grade Scales < or = 2 weeks after the infusion. Twenty were able to walk independently by 1 week, and 1 could be weaned off a ventilator. Eighteen children recovered by 2 weeks. The rest recuperated in a period of four months, including a child who was artificially ventilated for 4 weeks. The uniform rapid improvement and recovery associated with immune globulins contrasts with the slow recovery course in severe natural cases. We conclude that immune globulins are effective and safe in severe childhood-onset Guillain-Barré syndrome and therefore may serve as the initial treatment of choice.

Association of anti-GM2 antibodies in Guillain-Barré syndrome with acute cytomegalovirus infection

We examined serum anti-cytomegalovirus (CMV) and anti-ganglioside antibodies by ELISA in 51 patients with Guillain-Barré syndrome (GBS), and titers were compared with those from 47 normal and 74 disease controls. Three GBS patients with IgM anti-CMV antibodies had high titers of IgM and IgG anti-GM2 antibodies. The other GBS patients without IgM anti-CMV antibodies, and the normal and disease controls except one of 6 non-GBS patients with acute CMV infections had no anti-GM2 antibodies. The titers of anti-GM2 antibodies decreased on absorption with CMV-infected cells. These findings suggest that anti-GM2 antibodies are associated with acute CMV infections in GBS patients.

Human herpes viruses latent infection in the nervous system

The neurotropic herpes viruses, HSV-1, HSV-2 and VZV, colonize and establish latent infection in human peripheral sensory ganglia. Recurrent diseases due to reactivation of these viral pathogens can take place despite an effective immune response. Molecular, cellular, physiological and immune mechanisms work in concert to enable the establishment of latency, the maintenance of the latent state for the entire life of the host, and the reactivation infection. Although all three viruses belong to the same family and establish latent infection in the same tissue, the clinical pattern of their reactivation is quite different. This review covers current knowledge of the basis of these infections, and offers a theory explaining the basis of HSV-1 latent infection and the differences of the disorders caused by HSV-1 and VZV reactivation in humans.

The incidence of Guillain-Barre syndrome in Ferrara, Italy: is the disease really increasing?

The Guillain-Barre syndrome (GBS) incidence has been updated in the area of the Local Health District of Ferrara, Unita Sanitaria Locale n. 31 (USL 31), Northern Italy, (where a previous survey found an average annual incidence of 1.26/10000 population) in order to verify a supposed increase in GBS occurrence. The updated mean annual incidence over the years from 1981 to 1993 (average resident population: 177235 inhabitants) was 1.87/100000 population (1.66/100000 when age-adjusted). The rate increased progressively in the four subsequent time intervals into which the study period was subdivided (from 1.09/100000 in the years 1981-1984 to 2.73/100000 in the years 1991-1993) with a significant temporal variation (0.025 <p <0.05). The incidence was higher in the urban centres than in the rural zone of USL 31 (2.22/100000 and 1.10/100000; 0.025 <p <0.05) and an increase of GBS risk in the urban area was found. The incidence showed an increase in the oldest age groups of the study population. These findings seem to confirm a slight increase of GBS risk in the area of Ferrara with particular reference to urban centres and elderly people.

Guillain-Barré syndrome in children: a cooperative study in Taiwan

Seventy-two children with Guillain-Barré syndrome (GBS), diagnosed at 11 major teaching hospitals in Taiwan during the period 1986-1990, were studied retrospectively. There were 44 males and 28 females ranging in age from 7 months to 15 years. Preceding events could be traced in 61 patients (85%), including antecedent infection in 59 patients and previous vaccination in 2. As well as the consistent pictures of progressive weakness and generalized hyporeflexia, there were sensory complaints (26%), cranial nerve lesions (46%), respiratory failure (14%) and autonomic dysfunction (25%). Motor symptoms reached a maximum within 20 days in 88% of the patients, with the plateau lasting less than 2 weeks in 75%, and became stable within 3 months in 76%. Overall outcome showed complete recovery in 73% of the patients within 6 months after onset. Four (5.6%) had recurrence, and there was no mortality. The present study revealed that the annual incidence of GBS in Taiwan can be estimated roughly as 0.66 per 100,000 and that the course of childhood GBS is relatively benign.

Guillain-Barré syndrome following immunisation with Haemophilus influenzae type b conjugate vaccine

The Guillain-Barré syndrome (GBS) is an immune-mediated disease often associated with viral or bacterial infections and with immunisation. IgM antibodies have been implicated as the main trigger event in GBS. So far, only four cases of GBS have been observed following immunisation with a conjugate vaccine against Haemophilus influenzae type b. We report another patient with GBS after this vaccination. We measured immunoglobulins against the H. influenzae type b polysaccharide (PRP) component of the vaccine. Surprisingly the anti-PRP IgM antibody level was markedly elevated (100 micrograms/ml) in the plasma of this patient. We speculate that an excessive anti-PRP IgM antibody response to the vaccine might be the cause of GBS.

Gangliosides and bacterial toxins in Guillain-Barré syndrome

Autoimmune factors are strongly favoured as mediating Guillain-Barré syndrome (GBS); however, the precise mechanisms by which this occurs remain unknown. Microbial infections in a susceptible host resulting in an idiosyncratic immune response which cross-reacts with nerve constituents still remains the most plausible working hypothesis on which much current research is based. Considerable recent evidence indicates that this humoral immune response is at least in part directed to gangliosides. Interestingly, many bacterial toxins, including botulinum and tetanus neurotoxins, also bind to gangliosides and induce diseases with some similarities to GBS. This article discusses the evidence in favour of a pathogenic role for anti-ganglioside antibodies in GBS in the context of our knowledge of the biology of gangliosides and the factors that determine their immunogenicity.

Antibody responses to P0 and P2 myelin proteins in Guillain-Barré syndrome and chronic idiopathic demyelinating polyradiculoneuropathy

Immunisation with the peripheral nerve myelin proteins P0 or P2 induces inflammatory neuropathy in animals. We sought antibodies with an ELISA to these proteins in 38 patients with acute Guillain-Barré syndrome (GBS), 32 patients with chronic idiopathic demyelinating polyradiculoneuropathy (CIDP), 31 patients with other neuropathies (ONP) and 26 normal control (NC) subjects. We discovered IgM antibodies to human P0 protein in the sera of 18.5% of the patients with GBS, 15.6% with CIDP, 6.4% with ONP and 3.8% of NC subjects. Of the sera which reacted with P0, sera from 4/7 of GBS, 3/5 of CIDP, 1/2 of ONP patients and 0/1 of NC subjects reacted with a synthetic P0 peptide representing residues 150-169 from the cytoplasmic portion of the molecule. IgG antibodies to P0 were slightly less common than IgM antibodies, being present in only 7.9% of GBS, 0% of CIDP and 3% of ONP patients and 0% of NC subjects. We found antibodies to bovine P2 protein more commonly than antibodies to P0. IgM antibodies were present in 39.5% of GBS, 34.4% of CIDP, 16.1% of ONP patients and 15.4% of NC subjects. IgG antibodies were present in 18.4% of GBS, 12.5% of CIDP, 3.2% of ONP patients and 7.6% of NCs. Of the sera which contained antibodies to P2 protein, only a few reacted with P2 peptides 14-25 or 58-81, but without any consistent pattern of reactivity.(ABSTRACT TRUNCATED AT 250 WORDS)

Cell adhesion molecules of the immunoglobulin supergene family as tissue-specific autoantigens: induction of experimental allergic neuritis (EAN) by P0 protein-specific T cell lines

The P0 glycoprotein is a homophilic cell adhesion molecule of the immunoglobulin supergene family which is responsible for maintaining the structure of compact internodal myelin in the peripheral nervous system (PNS). Utilizing a panel of synthetic P0 peptides two distinct T cell epitopes have been identified that can induce T cell-mediated experimental autoimmune neuritis (EAN) in the Lewis rat. One T cell epitope (amino acid residues 56-71), is located within the extracellular, immunoglobulin-like domain of P0, while the other disease-inducing T cell epitope (residues 180-199) is located within the proteins cytoplasmic carboxyterminal domain. The adoptive transfer of 10(6) CD4+ T line cells specific for either of these peptide antigens induced EAN in syngeneic recipients. However, while the pathogenic response induced by both peptide-specific T cell lines was identical, their epitopes differ markedly in their immunologic properties in vivo. In particular while the response to peptide p180-199 was immunodominant in animals immunized with either purified P0 protein or the native membrane-bound P0 protein in autologous rat peripheral nerve myelin, no response to peptide p56-71 was detected, indicating that this epitope is cryptic. This study provides the first experimental evidence that the immunoglobulin-like domains of members of the immunoglobulin supergene family can function as target autoantigens in T cell-mediated autoimmune disease.

Antibody-mediated neurological disease

The number of neurological disorders in which autoantibodies are thought to play a pathogenic role continues to increase although the strength of the evidence varies. Many of the disorders are tumour associated.