Plasma exchange and intravenous immunoglobulin treatment of neuromuscular disease

Therapeutic Plasma Exchange Versus FcRn Inhibition in Autoimmune Disease

Therapeutic plasma exchange (TPE or PLEX) is used in a broad range of autoimmune diseases, with the goal of removing autoantibodies from the circulation. A newer approach for the selective removal of immunoglobulin G (IgG) antibodies is the use of therapeutic molecules targeting the neonatal Fc receptor (FcRn). FcRn regulates IgG recycling, and its inhibition results in a marked decrease in circulating autoantibodies of the IgG subtype. The difference between FcRn inhibition and PLEX is often questioned. With anti-FcRn monoclonal antibodies (mAbs) and fragments only recently entering this space, limited data are available regarding long-term efficacy and safety. However, the biology of FcRn is well understood, and mounting evidence regarding the efficacy, safety, and potential differences among compounds in development is available, allowing us to compare against nonselective plasma protein depletion methods such as PLEX. FcRn inhibitors may have distinct advantages and disadvantages over PLEX in certain scenarios. Use of PLEX is preferred over FcRn inhibition where removal of antibodies other than IgG or when concomitant repletion of missing plasma proteins is needed for therapeutic benefit. Also, FcRn targeting has not yet been studied for use in acute flares or crisis states of IgG-mediated diseases. Compared with PLEX, FcRn inhibition is associated with less invasive access requirements, more specific removal of IgG versus other immunoglobulins without a broad impact on circulating proteins, and any impacts on other therapeutic drug levels are restricted to other mAbs. In addition, the degree of IgG reduction is similar with FcRn inhibitors compared with that afforded by PLEX. Here we describe the scientific literature regarding the use of PLEX and FcRn inhibitors in autoimmune diseases and provide an expert discussion around the potential benefits of these options in varying clinical conditions and scenarios.

Role of cytokines and Toll-like receptors in the immunopathogenesis of Guillain-Barré syndrome

Guillain-Barré syndrome (GBS) is an autoimmune disease of the peripheral nervous system, mostly triggered by an aberrant immune response to an infectious pathogen. Although several infections have been implicated in the pathogenesis of GBS, not all such infected individuals develop this disease. Moreover, infection with a single agent might also lead to different subtypes of GBS emphasizing the role of host factors in the development of GBS. The host factors regulate a broad range of inflammatory processes that are involved in the pathogenesis of autoimmune diseases including GBS. Evidences suggest that systemically and locally released cytokines and their involvement in immune-mediated demyelination and axonal damage of peripheral nerves are important in the pathogenesis of GBS. Toll-like receptors (TLRs) link innate and adaptive immunity through transcription of several proinflammatory cytokines. TLR genes may increase susceptibility to microbial infections; an attenuated immune response towards antigen and downregulation of cytokines occurs due to mutation in the gene. Herein, we discuss the crucial role of host factors such as cytokines and TLRs that activate the immune response and are involved in the pathogenesis of the disease.

Therapeutic plasma exchange: a technical and operational review

Therapeutic plasma exchange (TPE) is an extracorporeal blood purification technique designed for the removal of large molecular weight substances. Examples of these substances include pathogenic autoantibodies, immune complexes, cryoglobulins, myeloma light chains, endotoxin and cholesterol containing lipoproteins. The basic premise of the treatment is that removal of these substances will allow for the reversal of the pathologic processes related to their presence. This review will cover the techniques for performing TPE, the kinetics of the removal of large molecules from the plasma and the benefits and risks of the different types of replacement fluids.

Role of Campylobacter jejuni infection in the pathogenesis of Guillain-Barré syndrome: an update

Our current knowledge on Campylobacter jejuni infections in humans has progressively increased over the past few decades. Infection with C. jejuni is the most common cause of bacterial gastroenteritis, sometimes surpassing other infections due to Salmonella, Shigella, and Escherichia coli. Most infections are acquired due to consumption of raw or undercooked poultry, unpasteurized milk, and contaminated water. After developing the diagnostic methods to detect C. jejuni, the possibility to identify the association of its infection with new diseases has been increased. After the successful isolation of C. jejuni, reports have been published citing the occurrence of GBS following C. jejuni infection. Thus, C. jejuni is now considered as a major triggering agent of GBS. Molecular mimicry between sialylated lipooligosaccharide structures on the cell envelope of these bacteria and ganglioside epitopes on the human nerves that generates cross-reactive immune response results in autoimmune-driven nerve damage. Though C. jejuni is associated with several pathologic forms of GBS, axonal subtypes following C. jejuni infection may be more severe. Ample amount of existing data covers a large spectrum of GBS; however, the studies on C. jejuni-associated GBS are still inconclusive. Therefore, this review provides an update on the C. jejuni infections engaged in the pathogenesis of GBS.

Diagnosis and treatment of primary Sjögren syndrome-associated peripheral neuropathy: a six-case series

OBJECTIVES

The clinical and therapeutic aspects of primary Sjögren syndrome (PSS) in patients with peripheral neuropathy were analyzed and the specifics of individual case studies are discussed.

METHODS

We retrospectively studied six patients (four women, two men; mean age 64.5 years) presenting with PSS with peripheral neurological involvement over a five-year period (2008-2012). All patients had neurological examinations, including nerve conduction studies, somatosensory evoked potentials, and sural nerve biopsies. Treatment regimens included corticosteroids, intravenous gammaglobulin, or immunosuppressive treatment.

RESULTS

Peripheral neuropathy was observed in six (7.9 %) of 76 patients with SS as the underlying disease; three were cases of multiple mononeuropathy, two cases had sensory ataxic neuropathy, one of which was autonomic neuropathy, and one case was diagnosed as painful sensory neuropathy without sensory ataxia. Four of the six patients were diagnosed with SS after the onset of neurological symptoms. Individual peripheral neuropathies had distinct neurological, electrophysiological, and pathological characteristics. The effect of steroids and intravenous gammaglobulin differed depending on the case.

CONCLUSIONS

In PSS patients, a precise diagnosis is important, because the therapeutic strategy and response varies depending on the type of neuropathy. In clinical practice, it is important to consider a diagnosis of SS when patients present with peripheral neuropathy.

Ganglioside mimicry and peripheral nerve disease

Four criteria must be satisfied to conclude that a given microorganism causes Guillain-Barré (GBS) or Fisher (FS) syndrome associated with anti-ganglioside antibodies: (1) an epidemiological association between the infecting microbe and GBS or FS; (2) isolation in the acute progressive phase of illness of that microorganism from GBS or FS patients with associated anti-ganglioside IgG antibodies; (3) identification of a microbial ganglioside mimic; and (4) a GBS or FS with associated anti-ganglioside antibodies model produced by sensitization with the microbe itself or its component, as well as with ganglioside. Campylobacter jejuni is a definitive causative microorganism of acute motor axonal neuropathy and may cause FS and related conditions. Haemophilus influenzae and Mycoplasma pneumoniae are possible causative microorganisms of acute motor axonal neuropathy or FS. Acute and chronic inflammatory demyelinating polyneuropathies may be produced by mechanisms other than ganglioside mimicry.

Syndrome de Guillain-Barré sévère et grossesse : deux cas d’amélioration rapide en post-partum

INTRODUCTION

Guillain-Barré syndrome can occur at any time of pregnancy with the same incidence as in the general population. Observations. We report two cases of patients who developed a progressive ascending paralysis during the second trimester of pregnancy. The worsening of the respiratory insufficiency for one of them required a transfer to an intensive care unit for artificial ventilation lasting 102 days. In the two cases, cerebrospinal fluid examination revealed albumin-cytological dissociation and repeated electrophysiological studies showed typical features of demyelinating neuropathy with conduction blocks. Biological investigations, especially CMV and Campylobacter jejuni serologies, were all negative. Intravenous immunoglobulin infusions, in one case associated with high doses of corticosteroïds, were ineffective. Rapid improvement was observed in the two patients after delivery.

CONCLUSION

These cases raise the question of the relationships between the Guillain-Barré syndrome and pregnancy. The occurrence of the disease, as well as the rapid recovery in post-partum, could be consecutive to a partial failure of the maternal immunological tolerance toward the fetus.

Factors influencing outcome in Guillain–Barré Syndrome: comparison of plasma adsorption against other treatments

OBJECTIVE

This study was performed to evaluate which factors influence the outcome of Guillain-Barré Syndrome (GBS), focusing on the choice of treatments.

METHODS

Sixty-three GBS patients were retrospectively studied and the following factors were evaluated: sex, age, days from onset of disease to the start of treatment, severity of symptoms, prior infection, autonomic dysfunction, bulbar palsy, anti-ganglioside antibody, and disease form, as well as the choice of treatment. Plasma adsorption (PA, n=39), plasma exchange (PE, n=14), or immunoglobulin treatment (IVIg, n=10) were performed in this study. Outcomes were evaluated using the functional grading scale (FGS) of Hughes.

RESULTS

The number of days needed for one functional grade improvement was significantly longer in the elderly, the severe symptom group, and patients with acute motor axonal form, and days needed for two functional grade improvement was significantly longer in the elderly, patients with autonomic dysfunction, and acute motor axonal form. The choice of treatments (PA, PE, or IVIg) did not significantly influence the outcome as determined by both univariate and multivariate analysis.

CONCLUSION

Although patient age, symptoms, and disease form influenced the outcome, treatment methods did not significantly influence the outcome. Since PA does not result in a risk of unknown infection, choosing a PA treatment may be justified, especially for patients (or doctors) who may be anxious about a possibility of unknown infection.

Peripartum cardiomyopathy

OBJECTIVE

To provide a review of the cardiac and obstetrical literature regarding the development of peripartum cardiomyopathy and, in particular, to examine risk factors, incidence, diagnosis, prognosis, and evidence-based treatment modalities.

DESIGN

An extensive review of the current literature.

RESULTS

Peripartum cardiomyopathy is a cardiomyopathy of unknown cause that occurs in pregnant females, most commonly in the early postpartum period. It shares many clinical characteristics with idiopathic dilated cardiomyopathy but occurs at a younger age and is associated with a better prognosis. Diagnosis is based upon the clinical presentation of congestive heart failure and objective evidence of left ventricular systolic dysfunction. Conventional pharmacologic therapy for congestive heart failure, such as diuretics, digoxin, angiotensin-converting enzyme inhibitors, angiotensin-receptor blockers, and beta-adrenergic blockers, are routinely used and are quite effective. For those patients who remain refractory to conventional pharmacologic therapy, cardiac transplantation and mechanical circulatory support are viable options.

CONCLUSION

Mortality rates in peripartum cardiomyopathy have decreased, and this is most likely related to advances over the past 5 yrs in medical therapy for heart failure. Aggressive use of implantable defibrillators has significantly reduced the risk of sudden death in these patients. For >50% of peripartum cardiomyopathy patients, left ventricular function normalizes with pharmacologic therapy. However, subsequent pregnancies almost always are associated with recurrence of left ventricular systolic dysfunction.

Plasmapheresis treatment in Guillain-Barré syndrome: potential benefit over IVIg in patients with axonal involvement

Response to therapeutic plasma exchange (TPE) was evaluated in patients diagnosed with Guillain-Barré Syndrome (GBS). Our aim was to assess response to TPE in patients who had failed treatment with intravenous immune globulin (IVIg). We conducted a retrospective chart review of 10 patients with the diagnosis of Guillain-Barré Syndrome who required TPE. Patients were identified by reviewing data from log books for TPE at The University of Connecticut Health Center, Farmington CT, USA. Patients who had failed IVIg treatment prior to being referred for TPE were also identified. Eight out of 10 patients treated with TPE showed improvement in their neurological exam. Four patients had axonal involvement on electromyelogram (EMG). Three patients were referred for TPE after failing IVIg treatment. All three of these had axonal involvement on EMG. Three of the four patients with axonal involvement demonstrated improvement with TPE. TPE may be a superior treatment option as compared to IVIg in patients with GBS and EMG findings of axonal involvement.

High-dose immunoglobulin therapy for Guillain-Barré syndrome in Japanese children

BACKGROUND

Guillain-Barré syndrome (GBS) is an acute acquired demyelinating polyneuropathy, presumed to be immune-mediated. Intravenous immunoglobulin (IVIg) has been used to treat GBS and was found to be effective. However, a well-controlled study of pediatric GBS has not been conducted in Japan. Therefore, to evaluate the efficacy of IVIg in the treatment of GBS, an open-labeled study was performed in pediatric patients.

METHODS

Participants in the study were required to be younger than 15 years old, and diagnosed as having moderate or severe GBS. IVIg (400 mg/kg per day) was administered to patients for five consecutive days. Predefined outcome measures were defined on a seven-point scale of motor function (Hughes' functional grade [FG]).

RESULTS

Eleven patients were treated with IVIg. The median time taken to improve by one grade on the FG scale was 10.0 days after initial treatment. Two weeks after initial treatment, 72.7% of patients treated with IVIg improved by one or more grades, and 36.4% improved by two or more grades, measured on the FG scale. After 4 weeks an improvement by one or more grades was observed in 81.8% of patients, and two or more grades in 63.6% of patients. These improvement rates were markedly greater than would occur with the natural course of GBS1. Adverse events (subjective symptoms or abnormal laboratory findings) were observed in four patients, although all were temporary and mild.

CONCLUSIONS

The authors conclude that IVIg is a safe and effective treatment for childhood GBS, which shortens the time to recovery.

Plasma exchange versus double filtration plasmapheresis in the treatment of Guillain-Barré syndrome

Previous studies have shown that both plasma exchange (PE) and double filtration plasmapheresis (DFPP) are effective treatments in Guillain-Barré syndrome (GBS). Whether PE and DFPP have similar effects in GBS is not clear. This report compares the therapeutic effectiveness of PE and DFPP in GBS patients treated in 3 major hospitals in northern Taiwan. A total of 102 patients were included in this survey, including 39 with PE (hereafter PE group) and 63 with DFPP (hereafter DFPP group). Both groups showed significant improvement of disability scores after treatment. However, time to onset of effect was shorter (5.6 +/- 3.5 versus 7 +/- 3.4 days, p < 0.05), and changes of disability scores were more prominent (1.3 +/- 0.8 versus 0.8 +/- 0.8, p < 0.05) in the PE group than the DFPP group. Mortality and outcome after 6 months were not different between the 2 groups. In conclusion, both PE and DFPP are effective treatments in GBS. PE was superior to DFPP in short-term effectiveness. The long-term effectiveness was not different.

Myasthenia gravis

BACKGROUND

In myasthenia gravis (MG), the prototypic autoimmune disease, antibodies against acetylcholine receptors impair neuromuscular transmission and produce weakness. Although recognized for several hundred years, it has only been over the last three decades that effective treatments have become available for MG.

REVIEW SUMMARY

This review summarizes the principles of normal neuromuscular transmission, the clinical features of MG, and the tests available for its diagnosis. The current treatments for MG are discussed, including possible mechanisms of action and a discussion of potential adverse effects. When available, evidence-based justification for individual treatment options is given, and areas of controversy identified.

CONCLUSIONS

Significant improvements in the diagnosis and management of MG have been made over the last several decades. The available treatments either improve neuromuscular transmission directly, or suppress or modulate the pathogenic immune response in MG. Treatment is highly individualized and must take into account the severity of disease, the presence of other diseases, and the kinetics of response for the available treatments. This requires detailed knowledge of the mechanisms of action and possible adverse effects for each treatment. However, despite an optimistic outlook with modern treatment, the management of MG continues to be plagued by lack of efficacy in some, and significant adverse effects in most MG patients.

Plasma exchange for Guillain-Barré syndrome

BACKGROUND

Guillain-Barré syndrome is an acute symmetric, usually ascending and usually paralysing illness, due to inflammation of peripheral nerves. It is thought to be caused by autoimmune factors, such as antibodies. Plasma exchange removes antibodies and other potentially injurious factors from the blood stream. It involves connecting the patient's blood circulation to a machine which exchanges the plasma for a substitute solution, usually albumin. Several studies have evaluated plasma exchange for Guillain-Barré syndrome.

OBJECTIVES

To systematically review the evidence concerning the efficacy of plasma exchange for treating Guillain-Barré syndrome.

SEARCH STRATEGY

Search of the Cochrane Neuromuscular Disease Trial Register for randomised trials concerning plasma exchange in Guillain-Barré syndrome, search of the bibliographies of identified papers and enquiry from the authors of the papers.

SELECTION CRITERIA

Randomised and quasi-randomised trials of plasma exchange versus sham exchange or supportive treatment.

DATA COLLECTION AND ANALYSIS

Potentially relevant papers were scrutinised by two reviewers and the selection of eligible studies was agreed by them and a third reviewer. Data were extracted by one reviewer and checked by a second reviewer. Some missing data were obtained from the authors of studies.

MAIN RESULTS

Six eligible trials concerning 649 patients were identified, all comparing plasma exchange versus supportive treatment alone. Primary outcome measures ~bullet~Time to recover walking with aid In the only two trials for which this measure was reported, the median time to recover this ability was faster in the plasma exchange than the control group. ~bullet~Time to onset of motor recovery in mildly affected patients In the one trial for which this measure was available, the time was significantly shortened in the plasma exchange group. Secondary outcome measures ~bullet~Improvement in disability grade at four weeks In five trials, there were significantly more patients who had improved by one disability grade or more in the plasma exchange group as compared to the control group. Patients treated with plasma exchange fared significantly better in the following secondary outcome measures: time to recover walking without aid, percentage of patients requiring artificial ventilation, duration of ventilation, full muscle strength recovery after one year, and severe sequelae after one year. There were less patients with infectious events and cardiac arrhythmias in the plasma exchange than the control group. Subgroup analyses Plasma exchange was beneficial in patients with mild, moderate and severe (needing ventilation) Guillain-Barré syndrome. It was beneficial in patients with a disease duration of seven or less days and also in those with disease lasting more than seven days. However, in the only trial that enrolled patients up to 30 days from disease onset, the benefit of plasma exchange in patients treated after seven days was less apparent. Type of treatment Single studies showed that two plasma exchanges were significantly superior to none for mild Guillain-Barré syndrome and four to two for moderate Guillain-Barré syndrome, but that six were not superior to four for severe Guillain-Barré syndrome requiring ventilation. One study suggested that continuous flow plasma exchange was significantly superior to intermittent flow. Another study found no significant difference between the two techniques. The same study found a significantly higher rate of adverse events with fresh frozen plasma as the replacement fluid than albumin. Plasma exchange compared with cerebrospinal fluid filtration A single trial comparing these two treatments did not show any difference in outcomes but was too small to demonstrate equivalence.

REVIEWER'S CONCLUSIONS

Plasma exchange is the first and only treatment that has been proven to be superior to supportive treatment alone in Guillain-Barré syndrome. Consequently, plasma exchange should be regarded as the treatment against which new treatments, such as intravenous immunoglobulin, should be judged. In mild Guillain-Barré syndrome two sessions of plasma exchange are superior to none. In moderate Guillain-Barré syndrome four sessions are superior to two. In severe Guillain-Barré syndrome six sessions are no better than four. Continuous flow plasma exchange machines may be superior to intermittent flow machines and albumin to fresh frozen plasma as the exchange fluid. Plasma exchange is more beneficial when started within seven days after disease onset rather than later, but was still beneficial in patients treated up to 30 days after disease onset. The value of plasma exchange in children less than 12 years old is not known. There is insufficient evidence to determine whether cerebrospinal fluid filtration is equivalent to plasma exchange.

Paradigm shift in surgical approaches to thymectomy

BACKGROUND

Thymectomy is an established therapy in the management of myasthenia gravis (MG) used in conjunction with medical treatment. The optimal surgical approach to thymectomy, however, has remained controversial.

METHOD

The present review discusses the author's experiences of and the literature regarding the management of MG using the video-assisted thoracic surgery (VATS) approach.

RESULTS

This approach was shown to be technically safe in experienced hands and associated with less postoperative pain, better preservation of lung function in the early postoperative period and better cosmetic results than alternative techniques. The intermediate term results of VATS are comparable to those of more radical approaches. It is hoped that this patient-friendly approach will lead to greater support by patients and their neurologists, for earlier surgery.

CONCLUSION

VATS is an attractive, alternative approach to thymectomy.

Myasthenia gravis: options and timing of immunomodulatory treatment

The autoimmune pathogenesis of myasthenia gravis is relatively well understood. The current options for treatment of this disease are acute and long term immunotherapies, acetylcholinesterase inhibitors and thymectomy. Many factors influence the timing of initiation of immunomodulatory therapy in myasthenia gravis and both disease factors, such as stage and severity, and patient factors, such as age, pregnancy and intercurrent illness, must be considered. Decisions regarding the choice of therapy can be difficult because of the limited number of randomised controlled trials that have been performed in myasthenic patients. In general, acetylcholinesterase inhibitors alone are used only in mild ocular disease, and in the majority of other patients immunomodulatory therapy is begun early. Corticosteroids are the most commonly used initial therapy, followed by azathioprine. In refractory cases, the available options include immunosuppressants such as cyclosporin, mycophenolate mofetil and cyclophosphamide. Plasmapheresis and intravenous immunoglobulin are important in the treatment of acute exacerbations and myasthenic crisis and in the perioperative setting. Despite many years of experience, the role of thymectomy in improving long term outcome in nonthymomatous myasthenia gravis remains controversial.

Diabetic Lumbosacral Polyradiculoneuropathies

The pathogenic basis and treatment of diabetic polyradiculoneuropathy is a source of recent controversy as there may be two or more distinct forms of diabetic polyradiculoplexopathy. We believe that the following two categories of diabetic polyradiculoneuropathy can be made on the basis of clinically differences: 1) the more common asymmetric, painful polyradiculoneuropathy; and 2) the rare symmetric, painless, polyradiculoneuropathy. The asymmetric, painful form (also known as diabetic amyotrophy) may have an autoimmune basis, but the etiology is not clear. The natural history for diabetic amyotrophy is spontaneous improvement. Nevertheless, various immunotherapies (eg, corticosteroids and intravenous immunoglobulin (IVIg) have been tried with subsequent improvement in symptoms. Treatment is reserved only for patients with severe ongoing pain, given the significant side effects of these medications in those patients with diabetes. Prednisone and IVIg may help alleviate the pain associated with diabetic amyotrophy. Relief of pain can help patients begin physical therapy earlier, however, there are no prospective, blinded, controlled studies that demonstrate that these treatments lead to an earlier and better recovery of muscle strength compared with the natural history of the disorder. The symmetric, painless form of diabetic polyradiculoneuropathy may in fact represent chronic inflammatory demyelinating polyneuropathy (CIDP) occurring in a patient with diabetes mellitus (DM). Patients with idiopathic CIDP may improve various immunomodulating therapies, including corticosteroid treatment, plasma exchange (PE), and IVIg. In this regard, patients with the symmetric, painless, proximal diabetic polyradiculoneuropathy may also respond to corticosteroids, plasma exchange, IVIg, azathioprine, or cyclophosphamide. However, as with diabetic amyotrophy, some patients improve spontaneously without treatment. In still other patients, the neuropathy appears unresponsive to immunotherapy. In such patients, this polyradiculoneuropathy might be caused by metabolic dysfunction associated with DM. Unfortunately, from a clinical, laboratory, and electrophysiologic standpoint, it is impossible to distinguish the patients with a symmetric, painless diabetic polyradiculoneuropathy who might respond to therapy. A trial of PE can be useful in identifying patients who might have a polyradiculoplexopathy that is responsive to immunotherapy. If patients respond to PE, they may continue to receive intermittent exchanges or be switched over to prednisone or IVIg.

Guillain-Barré Syndrome

Guillain-Barré syndrome (GBS) is an acute immune-mediated polyneuropathy. Two thirds of GBS patients are unable to walk at their most severe state of disease. Respiratory insufficiency and autonomic failure are probably the main causes of death. Optimal general care, physiotherapy and the availability of intensive care facilities at short distance are of great importance. Randomized controlled trials show that intravenous immune globulin (IVIg) and plasma exchange (PE) are equally effective in reducing the time to functional recovery. The combination of PE followed by IVIg, is not significantly better than IVIg or PE alone. Corticosteroids alone are not effective in GBS. Approximately 10% of GBS patients deteriorate after initial improvement or stabilization following IVIg or PE treatment, and often require repeated treatment. These "treatment related clinical fluctuations" are more frequently seen in relatively young patients with severe motor and sensory involvement associated with a preceding and possibly ongoing cytomegalovirus infection. Predominantly motor GBS is frequently preceded by a Campylobacter jejeuni infection. Diarrhea prior to GBS is associated with a worse predicted outcome. Further confirmation is needed to determine whether this is especially the case in those patients treated with PE. GBS patients who are unable to walk without assistance, and who are still within their first 2 weeks of the disease, need to be treated. One PE study showed that patients who are only mildly disabled showed positive progress from two plasma exchange sessions. Presently, due to its wide availability, ease of administration, and favorable side-effect profile, IVIg is considered to be the first-line treatment for patients with GBS. Current investigations are trying to determine if IVIg used in combination with methylprednisolone is even more effective in treating GBS.

Therapeutic apheresis in myasthenia gravis

Plasma exchange (PE) is an easily applicable technique for rapid and massive removal of antibodies, and its beneficial role is well established in the management of myasthenia gravis (MG), an antibody-mediated disorder of the neuromuscular junction. PE is useful in myasthenic crisis, in most severe forms of MG before thymectomy, in the early postoperative period, and in cases of symptom worsening during tapering or initiation of immunosuppressive therapy. Clinical efficacy varies from 55% to 100%, and improvement rarely persists for more than 4-10 weeks; thus immunosuppressive therapy has to be associated. New apheretic techniques (double filtration plasmapheresis, immunoadsorption systems with staphylococcal protein A columns or thryptophan-polyvinyl alcohol gel columns) that allow the selective removal of IgG and anti-AChR antibody were recently used in the management of MG with positive effects. Whether their therapeutic effect and cost effect prove more favorable than those obtained by PE still must be demonstrated.

Predictable recovery from myasthenia gravis crisis with plasma exchange: thirty-six cases and review of current management

Adult, acquired, idiopathic, autoimmune myasthenia gravis has a well-characterized IgG anti-acetylcholine striated-muscle receptor antibody. Removal by plasma exchange is effective, established therapy to augment anti-cholinesterase and immunosuppressive therapy and is the treatment of choice for myasthenia gravis crisis. We report 36 consecutive patients referred and accepted for plasma exchange, 32 of whom were in or entering myasthenia crisis, over a 10 year period. An average of 7.8 (range 1 to 16) plasma exchange procedures were done, with uniform, significant improvement, including extubation of 13 in myasthenic crisis and discharge from hospital in all. We conclude that this is the best treatment for myasthenia gravis crisis in hospital. From recent cases, most, if not all, crises can be prevented by IVIgG or plasma exchange as out-patients with use of corticosteroid and or azathioprine.

Apheresis and selective adsorption plus immunoglobulin treatment in Guillain-Barré syndrome

Plasma exchange (PE) and administration of intravenous immunoglobulin (i.v. IgG) are established treatments for Guillain-Barré syndrome (GBS). Combination treatment with elimination of postulated pathogenetic factors by PE or selective adsorption (SA) treatment and subsequent immunomodulation by intravenous IgG may provide a more effective treatment. In a single-center randomized study, 45 patients with acute GBS were prospectively examined using a clinical score. We treated 11 patients by PE, 13 with SA using a tryptophan-linked polyvinyl alcohol gel adsorbent, and 21 with SA followed by intravenous IgG. The patients treated sequentially by selective adsorption and intravenous IgG improved significantly better than the patients who received plasma treatment only. The results suggest that combination treatment of GBS may be superior to plasma treatment alone.

Degeneration of rabbit sensory neurons induced by passive transfer of anti-GD1b antiserum

Systemic infusion of high-titer anti-GD1b antiserum to two rabbits pre-inoculated with keyhole limpet hemocyanin and Freund's complete adjuvant was performed. The two rabbits had low-titer anti-GD1b antibody in sera. Although no apparent clinical signs were observed, pathological examinations showed vacuolar degeneration with macrophage infiltration in a few axons in the dorsal columns of the spinal cords from the two rabbits. No such pathological changes were observed in the other two pre-inoculated rabbits infused with normal rabbit sera. Anti-GD1b antibody therefore may cause degeneration in rabbit sensory neurons with central axons extending to the dorsal column.

Prednisone and plasma exchange improve suppressor cell function in chronic inflammatory demyelinating polyneuropathy

We have recently demonstrated that ConA-induced suppressor cell function is defective in chronic inflammatory demyelinating polyneuropathy (CIDP). To assess whether this defect plays a role in disease activity and its reversal is important in recovery, we studied modifications of ConA-induced suppressor cell function induced by prednisone and plasma exchange in 20 patients with CIDP. We found a significant increase towards normal of ConA-induced suppressor cell function after treatment in concurrence with clinical improvement. Induction of suppression, presumably through favorable modifications of the cytokine network or other humoral mediators, might be one, among others, of the mechanisms through which prednisone and plasma exchange are effective in CIDP.

Treatment of the adult Guillain-Barré syndrome: indications for plasma exchange

The Guillain-Barré syndrome is the most common cause of acute flaccid paralysis. Currently, 5% of patients die and 10% are left with severe motor sequelae at one year. Multidisciplinary teams, trained to specific treatments, are required to manage these patients. Oral and intravenous steroid treatment of GBS has been disappointing. Two large randomized clinical trials comparing plasma exchange (PE) to standard supportive treatment have shown a short-term and a one-year benefit of PE. Appropriate number of exchanges and indications of PE are now more precisely known. Patients with mild forms of the disease (able to walk) should receive two PEs, while a further two exchanges should be done in case of deterioration or in advanced forms (loss of walking ability, mechanical ventilation). A greater number of exchanges does not appeared beneficial. More recently, two randomized trials produced some evidence that intravenous immune globulin (IVIg, 0.4 g/kg daily for five days) and PE had equivalent efficiency in advanced forms. The combination of PE with IVIg did not yield a significant advantage, but did increase cost and risk. In advanced forms, the choice between PE and IVIg depends on the contraindications of each treatment.

Video-assisted thoracoscopic thymectomy for myasthenia gravis

Thymectomy is an established therapy in the management of generalized myasthenia gravis, in addition to medical treatment. However, the optimal surgical approach to thymectomy has remained controversial. There are advocates for transternal, transcervical approaches or "maximal" thymectomy. Video-assisted thoracic surgery (VATS) presents a new approach to thymectomy and forms the basis of this article, in which we discuss patient selection, technique, and results. We believe complete thymectomy, comparable with the transternal approach, could be achieved by VATS. Our intermediate-term results compare well with other surgical techniques. By minimizing chest wall trauma, VATS not only causes less postoperative pain, shortens hospital stay, gives better cosmetic results but also leads to wider acceptance by patients (and their neurologists) for earlier surgery. However, the true role of this approach in thoracic surgery awaits long-term results.

Comparative study of efficacy of plasma exchange versus intravenous gammaglobulin treatment on acute postinfectious polyradiculoneuropathy: a preliminary report

We tried to compare the efficacy of plasma exchange (PE) with that of intravenous immunoglobulin (IVIG) in patients with postinfectious polyneuritis (Guillain-Barré syndrome [GBS] and cranial neuritis). Fifteen patients with postinfectious polyneuritis were divided into 2 groups. The IVIG group included 5 cases of GBS and 2 cases of postinfectious cranial neuritis (ophthalmoplegic type). The PE group included 5 cases of GBS and 3 cases of postinfectious cranial neuritis (ophthalmoplegic type). The changes and incidences of improvement of muscle strength scores (MSSs) and ocular movement scores (OMSs) were evaluated before treatment and 1, 2, 3, and 4 weeks after treatment. No significant differences between the IVIG and PE groups were found in the MSSs or OMSs at any time after treatment. These data suggested that PE and IVIG had equivalent efficacy. In the IVIG group, the proportion of suppressor-inducer T cells significantly increased (p < 0.01) (before versus after treatment), and the proportion of suppressor-effector cells also increased but not significantly (before versus after treatment). In the PE group, the percentage of suppressor-inducer T cells significantly decreased (p < 0.05) (before versus after treatment) while the proportion of suppressor/cytotoxic T cells significantly increased (p < 0.05) (before versus after treatment). The percentage of suppressor-effector T cells also increased (before versus after treatment) but not significantly.

Treatment of chronic inflammatory demyelinating polyneuropathy

The management of chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) is the main topic of this review. A few comments will also be made about treatment of the demyelinating form of paraproteinaemic demyelinating polyneuropathy (PDN) and of multifocal motor neuropathy (MMN). The review briefly describes the main characteristics of these neuropathies, and examines case series and trials which evaluated the principal therapeutic strategies for CIDP, PDN and MMN, such as intravenous immunoglobulin (IVIg) therapy, steroid treatment, plasma exchange and immunosuppressor administration. Controlled trials demonstrated that IVIg, steroid treatment and plasma exchange are effective in CIDP. For PDN the therapeutic strategies are the same as for idiopathic CIDP, but usually the clinical response is poorer. For MMN, IVIg therapy is definitely the first choice treatment.

Natural and therapeutically-induced antibodies to cytokines

Serum samples obtained from non-immunocompromised patients treated therapeutically with recombinant cytokines (e.g. Il-1alpha; Il-1beta; Il-2 to Il-18; IFNalpha; GM-CSF; G-CSF; etc.) often reveal the presence of high affinity anti-cytokine antibodies. Antibody Fab binding in a saturable manner by ELISA and RIA or western immunoblotting prove their specificity. Antibody level often increases in these patients with repeated cytokine administration, suggesting boosts of antigen stimulation. However, the appearance in circulation of auto-antibodies to exogenous cytokine is not always associated with a decreased clinical response to therapy. The demonstration that non-neutralizing auto-antibodies to several natural cytokines can be found even in sera of normal healthy individuals never treated before with cytokines and particularly during the last trimester of pregnancy and in cord-blood, suggests that these naturally- occurring and therapeutically-induced auto-antibodies may exert different functions, not only as inhibitors or antagonists but also as beneficial physiological cytokine carriers or regulators of their activity.

Intravenous immunoglobulin preparation increases myoplasmic calcium concentration by activating the dihydropyridine-ryanodine receptor complex

A human intravenous immunoglobulin preparation (IVIg) released Ca2+ from the sarcoplasmic reticulum of cultured human skeletal muscle cells in a dose-dependent manner. Blocking the dihydropyridine-ryanodine receptor complex abrogated the IVIg-mediated Ca2+ response, whereas inhibition of the voltage-operated Na+-channels or acetylcholine receptors did not. This effect of IVIg was not mediated by its main component, the IgG molecules, and differed between preparations from different manufacturers. Heating destroyed the activity. Data shows that an unidentified serum protein present in IVIg can influence human muscle cells by an effect on the dihydropyridine receptor. This phenomenon may be important in interpreting the (side) effects of IVIg in neuromuscular diseases.

Ability to remove immunoglobulins and anti-ganglioside antibodies by plasma exchange, double-filtration plasmapheresis and immunoadsorption

In Japan, patients with Guillain-Barré (GBS) and Fisher's (FS) syndromes often receive plasma exchange (PE), double-filtration plasmapheresis (DFPP), or immunoadsorption (IA). To determine whether DFPP and IA are as effective as PE, we compared their abilities to remove immunoglobulins and anti-ganglioside antibodies. Plasma samples were obtained from 55 GBS patients and 53 FS patients, before and after each session of the treatments. PE decreased the IgG concentration more than DFPP did, its abilities to remove anti-ganglioside IgG antibodies in PE markedly being superior to the abilities of the other plasmaphereses. IA on a tryptophan-immobilized column adsorbed anti-ganglioside IgG antibodies more effectively than IA on other affinity columns.

Successful use of intravenous immunoglobulins in Landau-Kleffner syndrome

A detailed history of a boy with Landau-Kleffner syndrome is presented, demonstrating a close relationship between language functioning and paroxysmal electroencephalogram activity. During a 3-year 6-month follow-up period, three abrupt deteriorations of all language functions occurred: the child became totally noninteractive with his environment within 1 week's time. Two of these deteriorations were reversed with steroid treatment, with an identical recovery phase. Intravenous immunoglobulins had a very dramatic and comparable effect in the third relapse; both language functions and electroencephalogram abnormalities were influenced significantly by the intravenous immunoglobulin treatment.

Guillain-Barré syndrome with associated thrombocytopenia: prompt response to combined corticosteroid and immunoglobulin treatment

We report a case of Guillain-Barré syndrome (GBS), requiring prolonged mechanical ventilation, associated at its presentation with thrombocytopenia, in a 50-year-old woman. She was treated with immunoglobulin, and short-term corticosteroids for thrombocytopenia. In spite of the severe presentation we observed a very good and rapid recovery, which could have been determined by the therapeutic association. The incidence of thrombocytopenia in GBS patients could be underestimated, and should be kept in mind in order to avoid hemorrhagic complications.

Current immunotherapy in multiple sclerosis

The underlying pathophysiology of multiple sclerosis is presumed to be autoimmune in nature. Attempts to find an effective treatment for this common disease of the central nervous system have primarily focused on immune-mediated therapies, both immunosuppressive and immunomodulatory. The wide variety of immunological abnormalities detected in multiple sclerosis and its animal model, experimental allergic encephalomyelitis, has prompted the testing of a diverse array of drugs to be used for treatment. Recent successes in the treatment of relapsing-remitting multiple sclerosis with interferon beta and glatiramer acetate have renewed interest in and raised expectations for the effective control of this neurological disorder. Improved methodology in clinical trials, the development of surrogate markers and the availability of novel therapies bode well for more rapid advances.

Intravenous immunoglobulin treatment of neurological autoimmune diseases

Intravenous immunoglobulin (IVIg) has been widely used in neurological diseases during the last decade. The current indications of IVIg in neurological diseases are reviewed and discussed on the basis of the available experimental data and clinical trials. Compared to other immunomodulating treatments used in neurological diseases, IVIg has only few side effects with a small risk of transmission of infectious agents. Good clinical evidence for the effectiveness is available for Guillain-Barré-Syndrome, chronic inflammatory demyelinating polyneuropathy and multifocal motor neuropathy. In conditions like myasthenia gravis and myositis favourable effects of IVIg were reported, but future studies have to be awaited. For all other neurological conditions where IVIg has been administered, there is currently no support for the use of IVIg other than in controlled trials. In conclusion, IVIg is a promising immunomodulary therapy that has been shown to be effective in some neurological autoimmune diseases. Routine use in neurological practice should be restricted to diseases for which a positive effect has been proven in controlled trials. For all other conditions no definite recommendations can presently be made.

[Treatment of Guillain-Barré syndrome in adults: role of plasma exchange]

PURPOSE

To review recent data on treatment of Guillain-Barré syndrome, especially indications of plasma exchange.

DATA SYNTHESIS

Guillain-Barré syndrome is the most common cause of acute flaccid paralysis. The current mortality is 5%, sever motor sequelae persist after 1 year in 10% of cases. Multidisciplinary teams are required to treat these patients, trained to all specific treatments. Oral and intravenous steroids have proven ineffective. Two large randomized clinical trials comparing plasma exchange (PE) with no treatment have shown a short-term and a 1-year benefit. Appropriate number of exchanges and indications are now more precisely known. In mild form (walking possible), patients should receive two PEs. A further two exchanges should be done in case of deterioration or in advanced forms (loss of walking ability, mechanical ventilation). More exchanges are not beneficial. Recently two new randomized trials have produced evidence that intravenous immune globulin (IVIg) (0.4 g/kg/d for 5 days) were as effective as five PEs in advanced forms. The combination of PE with IVIg did not confer a significant advantage, while increasing cost and risks.

CONCLUSION

The combination of PE with IVIg did not confer, in advanced forms, the choice between PE and IVIg depends of the contra-indications of each treatment.

Ability to remove immunoglobulins and antiganglioside antibodies by double filtration plasmapheresis in Guillain-Barré syndrome: is it equivalent to plasma exchange?

The value of plasma exchange (PE) in Guillain-Barré syndrome (GBS) is well established. In Japan, patients with GBS and related diseases often receive double filtration plasmapheresis (DFPP) as well as PE. No comparative trials between PE and DFPP, however, have been conducted. We compared their abilities to remove immunoglobulins and antiganglioside antibodies to find out whether DFPP is equivalent to PE. The ability to remove immunoglobulins and antiganglioside antibodies was compared between PE and DFPP using plasma samples from 41 patients with GBS and related diseases before and after each treatment session. The ability of DFPP to remove both IgGs and antiganglioside IgG antibodies were significantly inferior to those of PE. There is a less theoretical basis for selecting DFPP as the first choice of plasmapheresis for GBS and related disorders.

Comparison of the adsorption ability between tryptophan and modified tryptophan columns

Immunoadsorption therapy (IAT) using the tryptophan column (TR:TR-350, Asahi Medical Co., Tokyo, Japan) is used for patients with Guillain-Barré syndrome or Fisher's syndrome. Recently, a modified tryptophan column (modified TR:TR-350S, Asahi) was developed to reduce adsorption of fibrinogens. However, it is not clear whether the new column can effectively adsorb the antiganglioside antibodies. We treated 2 patients with Guillain-Barré syndrome, 1 patient with Fisher's syndrome, and 1 patient with Bickerstaff's brainstem encephalitis by IAT using the TR and the modified TR. Samples were taken from the inlet and outlet of the affinity column. We compared the adsorption ability of antiganglioside antibodies between the TR and modified TR. The modified TR adsorbed antiganglioside antibodies less effectively than the TR. No significant bleeding was observed in the patients during each session. Furthermore, results of the clinical study were confirmed by batchwise adsorption test. We propose that the modified TR should not be used for treating patients with Guillain-Barré syndrome and related disorders.

Increased In Vivo Antibody Activity Against Interferon α, Interleukin-1α, and Interleukin-6 After High-Dose Ig Therapy

High-avidity antibodies against interferon α (IFNα), interleukin-1α (IL-1α), and IL-6 have been demonstrated in preparations of normal human IgG, and in vivo modulation of these cytokines may therefore account for immunomodulatory and anti-inflammatory effects of high-dose intravenous IgG therapy. We have investigated the in vivo recovery and the effect on serum cytokine levels of antibodies to IFNα, IL-1α, and IL-6 infused with IgG preparations. Fifteen treatment series of 0.4 g IgG/kg/d were administered over 3 days to eight patients with autoimmune diseases. All IgG preparations contained variable amounts of antibodies binding to 125I-labeled human IFNα2A, -IL-1α, and -IL-6, and the contents of these molecules correlated with increased levels in serum anticytokine activities after IgG infusion. The infused anti–IL-1α antibody activity was fully recovered, whereas the recovery of anti-IFNα2A antibodies was significantly reduced. Serum antiviral activities were significantly reduced after IgG therapy (before, 0 to 5.6 IU/mL; after, 0 to 0.6 IU/mL). In contrast, enzyme-linked immunosorbent assay (ELISA) showed no significant reduction in the serum levels of IL-6 (before, 1 to 70 pg/mL; after, 2 to 55 pg/mL), and the levels of IL-1α were consistently below the detection limit (<30 pg/mL). In conclusion, increased levels of antibodies to IFNα2A, IL-1α, and IL-6 occurred in patients receiving IgG and this reduced the serum antiviral activity.

Increased In Vivo Antibody Activity Against Interferon α, Interleukin-1α, and Interleukin-6 After High-Dose Ig Therapy

High-avidity antibodies against interferon α (IFNα), interleukin-1α (IL-1α), and IL-6 have been demonstrated in preparations of normal human IgG, and in vivo modulation of these cytokines may therefore account for immunomodulatory and anti-inflammatory effects of high-dose intravenous IgG therapy. We have investigated the in vivo recovery and the effect on serum cytokine levels of antibodies to IFNα, IL-1α, and IL-6 infused with IgG preparations. Fifteen treatment series of 0.4 g IgG/kg/d were administered over 3 days to eight patients with autoimmune diseases. All IgG preparations contained variable amounts of antibodies binding to 125I-labeled human IFNα2A, -IL-1α, and -IL-6, and the contents of these molecules correlated with increased levels in serum anticytokine activities after IgG infusion. The infused anti–IL-1α antibody activity was fully recovered, whereas the recovery of anti-IFNα2A antibodies was significantly reduced. Serum antiviral activities were significantly reduced after IgG therapy (before, 0 to 5.6 IU/mL; after, 0 to 0.6 IU/mL). In contrast, enzyme-linked immunosorbent assay (ELISA) showed no significant reduction in the serum levels of IL-6 (before, 1 to 70 pg/mL; after, 2 to 55 pg/mL), and the levels of IL-1α were consistently below the detection limit (<30 pg/mL). In conclusion, increased levels of antibodies to IFNα2A, IL-1α, and IL-6 occurred in patients receiving IgG and this reduced the serum antiviral activity.

Intravenous immunoglobulin as therapy for pediatric Guillain-Barré syndrome

Seven children with Guillain-Barré syndrome were treated with intravenous immunoglobulin. Median patient age was 5.8 years. A standard dosage of 0.4 g/kg/day for 5 days was administered. Clinical improvement occurred on average within 2.4 +/- 1.3 days of beginning intravenous immunoglobulin. One child required mechanical ventilation for 7 days. Eight comparable children with Guillain-Barré syndrome at our institution in a prior study treated with plasmapheresis alone had similar clinical results. However, the need for admission to the pediatric intensive care unit and duration of pediatric intensive care unit stay were lower in the intravenous immunoglobulin treated group (P < .05). There were no complications with intravenous immunoglobulin therapy except for a brief episode of hypotension in one patient. Review of the literature identified 74 additional children with Guillain-Barré syndrome successfully receiving intravenous immunoglobulin therapy. We suggest intravenous immunoglobulin as initial therapy for pediatric Guillain-Barré syndrome, because it appears equally as effective as plasmapheresis and is associated with fewer complications.

Idiopathic inflammatory myopathies

Dermatomyositis, polymyositis, and inclusion body myositis are the major categories of idiopathic inflammatory myopathy. These inflammatory myopathies are distinct clinically, histologically, and pathogenically. Features of dermatomyositis and polymyositis can overlap with those of other autoimmune connective tissue diseases. In this article, the authors review the characteristic features of these myopathies, update the recent developments in this area, and provide a framework for treatment.

Therapy of myasthenic crisis

OBJECTIVES

To investigate the frequency, causes, and characteristic features of the course of isolated myasthenic crisis (defined as acute respiratory failure with the need for mechanical ventilation). To compare the effectiveness of three different therapeutic regimens (i.e., continuous intravenous infusion of pyridostigmine, pyridostigmine plus prednisolone, and plasma exchange) in terms of duration of ventilation and outcome of patients with myasthenic crisis.

DESIGN

Population-based retrospective study covering the period 1970 to 1995.

SETTING

University hospital, center for myasthenia gravis in Saxony, Germany.

PATIENTS

Of 235 patients with myasthenia gravis treated at our institution, 44 patients developed a total of 63 myasthenic crises (average annual incidence 2.5%).

INTERVENTIONS

Myasthenic crises were treated with pyridostigmine (n = 24), pyridostigmine plus prednisolone (n = 18), and plasma exchange (n = 21).

MEASUREMENTS AND MAIN RESULTS

There were no significant differences between the three treatment groups with respect to clinical characteristics, duration of mechanical ventilation, complications, and outcome on release from intensive care and after 3 months. Eleven (17%) patients had severe cardiac arrhythmia, which ended fatally for six patients.

CONCLUSIONS

None of the therapeutic regimens applied demonstrated any advantage over the others. All three regimens used were found to be effective and should be applied depending on the circumstances prevailing. Patients with myasthenic crisis must undergo careful cardiac monitoring, and temporary pace-making should be provided where clinically indicated.