Cerebrospinal fluid immunoglobulins and virus-specific antibodies in disorders affecting the facial nerve

Search for Herpesviruses in cerebrospinal fluid of facial palsy patients by PCR

CONCLUSIONS

Herpes simplex virus 1 (HSV-1) and varicella-zoster virus (VZV) DNA were not detected in the cerebrospinal fluid (CSF) of patients with acute idiopathic peripheral facial palsy (Bell's palsy). Our results indicate either the absence of these viruses or the presence of technical shortcomings. The role of human herpesvirus 6 (HHV-6) in this disorder and the significance of a positive HHV-6 DNA finding in the central nervous system need further investigation.

OBJECTIVE

Our goal was to determine whether DNA of HSV-1, VZV, or HHV-6 can be found by polymerase chain reaction (PCR) in the CSF of peripheral facial palsy patients.

MATERIALS AND METHODS

We used PCR to detect the presence of HSV-1, VZV, and HHV-6 DNA in CSF. This was a retrospective case control study with 33 peripheral facial palsy patients (34 CSF samples) in the study group (26 with Bell's palsy, 5 with simultaneously diagnosed herpesvirus infection, 1 with puerperal facial palsy, 1 with Melkersson-Rosenthal syndrome). The control group included 36 patients, most with diagnosed or suspected Borreliosis and facial palsy or sudden deafness.

RESULTS

One patient with Bell's palsy had HHV-6 DNA in CSF. Neither HSV-1 nor VZV DNA was detected in patients or controls.

Bell's palsy: electrodiagnostics are not indicative of cerebrospinal fluid abnormalities

Electrodiagnostic testing (electromyography, electroneuronography, and blink reflex) and cerebrospinal fluid (CSF) examination (cell count, immunoglobulins, and antigen-specific intrathecal immunoglobulin G synthesis against herpes simplex virus, varicella zoster virus, cytomegalovirus, and Borrelia burgdorferi sensu latu) were performed in 56 patients with Bell's palsy. The CSF was normal in 45 patients and abnormal in 11 patients. Acute borreliosis was the most common specific pathological CSF finding (4 of 11). Electromyography revealed abolished volitional activity in 22% of patients with normal CSF and in 36% with pathological CSF. Electroneuronographic tests with an amplitude decrease of more than 90% on the affected side or abolished responses were found in 20% of patients with normal CSF and in 18% with pathological CSF. Abolished orbicularis oculi reflexes were seen in 67% of patients with normal CSF and in 82% with pathological CSF Concerning electrodiagnostic testing, no statistically significant difference between patients with normal and abnormal CSF was found, so we conclude that electrodiagnostic testing has no indicative value for abnormal CSF in Bell's palsy.

IgG index in acute idiopathic peripheral facial palsy

OBJECTIVES

Etiologic hypotheses in acute idiopathic peripheral facial palsy (AIPFP) mostly point to an immunologic dysfunction, probably virus-induced. Though various immunologic abnormalities are reported, the problem is still unsolved. We investigated intrathecal immunoglobulin synthesis in AIPFP as a clue for central nervous system (CNS) immunopathology.

MATERIAL AND METHODS

We studied IgG index in 24 patients with AIPFP, 10 with other neurological diseases (OND) and 17 with multiple sclerosis (MS). CSF and serum IgG were measured by radial immunodiffusion technique. IgG index is calculated according to Tibbling's formula.

RESULTS

IgG indexes were abnormal in 6 patients with AIPFP, 3 with OND and 10 with MS patients. There was no statistical difference between AIPFP and OND groups, while marked difference existed between AIPFP and MS groups.

CONCLUSION

Though IgG indexes were high in 25% of AIPFP patients, statistical analyses did not show any significance of this finding. Lack of a positive result might reflect non-existence of an extensive immunologic pathology within CNS, excluding a very limited one.

Acute "idiopathic" peripheral facial palsy: clinical, serological, and cerebrospinal fluid findings and effects of corticosteroids

INTRODUCTION

The causes for peripheral facial palsy remain obscure in many patients. Evidence exists suggesting viruses, especially those belonging to the herpesvirus group, may be causative. This study was developed to evaluate this theory.

METHODS

One hundred forty-seven patients with acute peripheral facial palsy of primarily unknown origin were studied. All were examined within 1 week of onset. Subsequent follow-up was undertaken until the palsy had recovered or become static. Paried cerebral spinal fluid and serum samples were obtained for serological evaluation to detect herpes simplex, varicella zoster, cytomegalovirus, measles, mumps, rubella, tick-borne encephalitis, adenovirus, Epstein-Barr virus, and human immunodeficiency virus, as well as the antibodies to Borrelia burgdorferi.

RESULTS

Elevated antibiotic titers to Borrelia burgdorferi were observed in 11% of patients, whereas 9% of patients demonstrated elevated viral titers. Antibody pattern consistent with Epstein-Barr virus reactivation was present in 13%. A total of 67% were classified as idiopathic.

CONCLUSION

Patients with reactivated Epstein-Barr virus were characterized by having a higher incidence of auricular pain and displayed diabetes mellitus in a higher frequency than in other groups. In the Borrelia group, neck/back pain was more common. Healing was less favorable in the Borrelia group despite an equal rate of palsy at onset and adequate antibiotic treatment. Corticosteroid treatment used in 44% of the patients did not significantly improve the functional outcome.

Epidemiology and clinical manifestations of Lyme borreliosis in childhood. A prospective multicentre study with special regard to neuroborreliosis

Lyme borreliosis is a tick-borne infection caused by the spirochete Borrelia burgdorferi, whose discovery in 1982 solved an aetiological mystery involving a variety of dermatological and neurological disorders and explained their association with Lyme disease. Lyme borreliosis occurs frequently and is readily treatable with antibiotics. Along with its discovery, however, came the realization that it is difficult to diagnose accurately, especially antibody diagnosis. False-positive antibody results in particular led to gradual widening of the clinical spectrum, and differential diagnosis became increasingly difficult. This prospective, multicentre study presents a systematic description of Lyme borreliosis in childhood, emphasizing epidemiological and clinical issues. Because, predominantly, inpatients were examined, Lyme neuroborreliosis was the focus of the study, with the chief concern being to minimize false-positive results. To this end, we chose to narrow the diagnostic criteria, using the presence of specific antibodies in the cerebrospinal fluid as the determining factor. The epidemiological investigation was focused on the incidence of Lyme neuroborreliosis in childhood in southern Lower Saxony as well as on the prevalence of Lyme neuroborreliosis among acute-inflammatory neurological illnesses in children. The clinical part of the study aimed at establishing criteria for differential diagnosis in addition to the detection of specific antibodies. The detection of specific IgM antibodies using an IgM capture ELISA confirmed the presence of acute Lyme borreliosis. The study examined 208 children with Lyme borreliosis, of whom 169 had Lyme neuroborreliosis, from mid-1986 until the end of 1989. The yearly incidence of Lyme neuroborreliosis in Lower Saxony was 5.8 cases/100,000 children aged 1 to 13. The manifestation index was 0.16, or one case of Lyme neuroborreliosis per 620 infected children, compared with the presence of specific antibodies against B. burgdorferi for children in the same age group and region. Both the seasonal distribution of Lyme borreliosis, which peaked in summer and autumn, as well as the information about when the tick bites took place point to an incubation period of a few weeks. The most frequent manifestation of Lyme neuroborreliosis in childhood was acute peripheral facial palsy, found in 55% of all cases (n = 93). Lyme borreliosis proved to be the most frequently verifiable cause of acute peripheral facial palsy in children, causing every second case of this disorder in summer and autumn.(ABSTRACT TRUNCATED AT 400 WORDS)

Acute peripheral facial palsy: CSF findings and etiology

CSF and serum were examined in acute and convalescence phase from 56 patients with acute idiopathic peripheral facial palsy. CSF protein analysis, viral and borrelia serology were performed. Borrelia infection was found in 9/56 cases and was often associated with inflammatory CSF findings. One patient each had serological evidence for a recent or ongoing infection with herpes simplex, varicella zoster, adeno, influenza B, echo and Epstein-Barr virus, but none had specific intrathecal antibody synthesis; 11 patients had a serological pattern compatible with a reactivated Epstein-Barr virus infection. Eleven patients displayed mononuclear CSF pleocytosis. Four of them had a borrelia infection. A disturbed blood-brain barrier was observed in 19 patients. Intrathecal immunoglobulin synthesis as indicated by elevated IgM-indices was found in 16 patients and by IgG indices in three. Nine patients had oligoclonal IgG bands in serum and CSF, three exclusively in CSF. It is concluded that patients with facial palsy often have inflammatory CSF findings, indicating a generalised central nervous system affection, and not only a mononeuritis. The importance of viral infections in the pathogenesis is still obscure. Borrelia is the most common infectious cause of facial palsy.

Peripheral facial palsy in childhood--Lyme borreliosis to be suspected unless proven otherwise

27 consecutive cases with acute peripheral facial palsy were studied for Lyme borreliosis. In 16 out of 27 children Lyme borreliosis could be diagnosed by detection of specific IgM antibodies in CSF. CSF findings allow a clear distinction according to etiology. All children with facial palsy due to Lyme borreliosis revealed lymphocytic CSF pleocytosis, whereas in cases of unknown etiology CSF was usually normal. Bilateral facial palsy occurred only in children with Lyme borreliosis. All cases with a positive history of tick bite and/or erythema migrans in the head-neck region showed ipsilateral neurological affection suggesting a direct invasion via the affected nerve by Borrelia burgdorferi.

Fine specificities of antibodies in sera and cerebrospinal fluid in herpes virus infections of the central nervous system as detected by the antigen variable immunoblot technique

Applying the immunoblot technique a sensitive and specific method was developed for the detection of intrathecally synthesized antibodies against individual specific proteins that are antigens of various infectious agents causing encephalitis. Paired serum and cerebrospinal fluid (CSF) samples from five patients with herpes virus infections of the central nervous system (CNS) (three herpes simplex virus encephalitis, one varicella zoster virus encephalitis, one zoster ganglionitis) were investigated for the presence of locally produced IgG against the electrophoretically separated antigens of herpes simplex virus (HSV), varicella zoster virus (VZV) and human cytomegalovirus (HCMV), as well as for IgM antibodies in one case of HSV encephalitis. In two cases (HSV encephalitis and VZV encephalitis) four and one antibody, respectively, were found that were synthesized intrathecally only. In the other cases the patterns of sera and CSF antibodies were similar, the CSF antibodies showing an all-over stronger reaction, at identical IgG concentrations. In contrast to the conception of a 'limited heterogeneity' of intrathecal antibody synthesis in encephalitis, we thus found an 'expanded heterogeneity' of the intrathecally synthesized antibodies in comparison to the corresponding serum antibodies.

Immunocytochemical analysis of immunoglobulin-containing cells in CSF and blood in inflammatory disorders of the central nervous system

Cells containing immunoglobulins G, A, and M were evaluated in paired cerebrospinal fluid (CSF) and peripheral blood (PB) samples. These were obtained from 12 patients with bacterial meningitis, 14 patients with viral meningitis, 6 cases of lymphocytic meningoradiculitis (LMR), 10 cases of multiple sclerosis (MS), 6 cases of herpes zoster ganglionitis and 27 patients with non-infectious disorders of the CNS. PB cells from 20 healthy donors served as controls. Using alkaline phosphatase (AP)-conjugated antibodies to human immunoglobulin (Ig) G, A, and M in a carrageenan solution it was possible to demonstrate repeatedly intracytoplasmic Igs over more than 1 year without any detectable loss of specificity and staining intensity. Immunoglobulin-containing cells (ICC) could be detected in the CSF of 96% of patients with inflammatory diseases of the central nervous system (CNS) or with MS but not in the control cases.

Chronic HIV encephalitis--II. Clinical aspects

Combined medical, neurological, and serological investigations were carried out in 59 patients infected with human immunodeficiency virus (HIV). In stage I clinical and neuropsychiatric testing did not reveal evidence for HIV encephalitis as diagnosed by local antibody production in CSF. Neuropsychiatric abnormalities, brain atrophy, memory and cognitive impairment reliably indicated HIV encephalitis in later stages. The commonest symptoms were cerebellar and brainstem signs, followed by dementia. Epileptic fits and hemiparesis always were associated with cerebral toxoplasmosis. A polyneuropathy was frequently found but other causes have to be considered.