Relapsing neuropathy due to tetanus toxoid. Report of a case

Guillain Barré syndrome after combined diphtheria, tetanus, and acellular pertussis (DTaP) vaccine: A rare pediatric case report and review of literature

A 20-month-old girl was diagnosed with Guillain - Barré syndrome (GBS) based on progressive muscle weakness, areflexia, and albuminocytologic dissociation of the cerebrospinal fluid. Despite timely and systematic treatment, she eventually became paralyzed. There is a temporal correlation between the girl's GBS and the DTaP vaccination, but the exact causal relationship between the two is still debatable. Furthermore, we summarized clinical features of other 45 published GBS cases after DTP vaccines (or vaccine substances containing tetanus) through a systematic review. The mean onset age, sex distribution, onset time after vaccination, detection of antiganglioside antibodies, and other basic clinical features of GBS after DTP vaccination (or vaccine substances containing tetanus) were analyzed. The temporal pattern of GBS after vaccination was similar to that of GBS after infection. Herein, we report this rare case of presumptive pediatric GBS after DTaP vaccination and review similar cases to draw the attention of medical personnel to similar events after vaccination. An association between DTP vaccines and GBS has been proposed, and the causal relationship between these two incidents are worthy further exploration. Moreover, surveillance and vigilance for GBS after vaccination are highly recommended.

Neurological sequelae of vaccines

IMPORTANCE

Vaccines are a safe and efficacious way to prevent a variety of infectious diseases. Over the course of their existence, vaccines have prevented immeasurable morbidity and mortality in humans. Typical symptoms of systemic immune activation are common after vaccines and may include local soreness, myalgias, nausea, and malaise. In the vast majority of cases, the severity of the infectious disease outweighs the risk of mild adverse reactions to vaccines. Rarely, vaccines may be associated with neurological sequela that ranges in severity from headache to transverse myelitis, acute disseminated encephalomyelitis, and Guillain-Barre syndrome (GBS). Often, a causal link cannot be confirmed, and it remains unclear if disease onset is directly related to a recent vaccination.

OBSERVATIONS

This review serves to summarize reported neurologic sequelae of commonly used vaccines. It will also serve to discuss potential pathogenesis. It is important to note that many adverse events or reactions to vaccines are self-reported into databases, and causal proof cannot be obtained.

CONCLUSIONS AND RELEVANCE

Recognition of reported adverse effects of vaccines plays an important role in public health and education. Early identification of these symptoms can allow for rapid diagnosis and potential treatment. Vaccines are a safe option for prevention of infectious diseases.

Inflammatory demyelinating polyneuropathy after the ChAdOx1 nCoV-19 vaccine may follow a chronic course

Background

Methods

Conclusions

Case Series of Guillain-Barré Syndrome After the ChAdOx1 nCoV-19 (Oxford-AstraZeneca) Vaccine

Purpose of Review

Vaccination has been associated with Guillain-Barre syndrome (GBS). Amid a global vaccination campaign to stop the spread of COVID-19, fears of GBS can contribute to vaccine hesitancy. We describe 3 cases of GBS in Calgary, Canada, presenting within 2 weeks of receiving the ChAdOx1 nCoV-19 (COVISHIELD) Oxford-AstraZeneca vaccination and review the available literature.

Recent Findings

All 3 patients presented to the hospital in Calgary, Alberta, Canada, within a one-month time frame with GBS. Their clinical courses ranged from mild to severe impairment, all requiring immunomodulatory treatment.

Summary

There is currently little evidence to support a causal relationship between vaccination and GBS. Furthermore, there is limited evidence to support recurrent GBS in patients with GBS temporally associated with vaccination. Neurologists should approach discussions with patients regarding GBS after vaccination carefully so as not to misrepresent this relationship and to educate patients that the risk of COVID-19 infection outweighs the small individual risk of a vaccine-associated adverse event.

Immune-mediated adverse reactions to vaccines

Vaccination continues to be the single most important and successful public health intervention, due to its prevention of morbidity and mortality from prevalent infectious diseases. Severe immunologically mediated reactions are rare and less common with the vaccine than the true infection. However, these events can cause public fearfulness and loss of confidence in the safety of vaccination. In this paper, we perform a systematic literature search and narrative review of immune-mediated vaccine adverse events and their known and proposed mechanisms, and outline directions for future research. Improving our knowledge base of severe immunologically mediated vaccine reactions and their management drives better vaccine safety and efficacy outcomes.

An Outbreak of Peripheral Neuropathy in a Prison

Prisoners are at risk for both physical and psychological diseases. Here, we report an outbreak of peripheral neuropathy in a prison in northeast Thailand. Between July and December 2014, there were 88 male prisoners at Bueng Kan Provincial Prison in Bueng Kan, Thailand suffering from peripheral neuropathy out of a total of 1,464 prisoners (6.01%). The common age range was 20–39 years (58 patients; 65.91%). The three most common features were hyporeflexia/areflexia of the lower extremities (36 patients; 83.72%). On laboratory vitamin B1 deficiency was detected in 4/5 patients, positive rhinovirus polymerase chain reaction in 3/4 patients, positive Mycoplasma pneumoniae IgM in 1/12 patients, and positive urinary arsenic in 4/7 patients. A dT vaccination was given on October 14 during the outbreak. This was a large outbreak of peripheral neuropathy in male prisoners. There are several possible causes of this outbreak including vitamin B1 deficiency, dT vaccination, arsenic toxicity, rhinovirus, and Mycoplasma infection.

Chronic inflammatory demyelinating polyradiculoneuropathy and variants: where we are and where we should go

Chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) is a chronic and often disabling sensory motor neuropathy postulated as caused by an immune attack against peripheral nerve myelin. In addition to a classic sensory–motor polyneuropathy, other phenotypes of CIDP have been described including the Lewis- Sumner syndrome, distal acquired demyelinating symmetric (DADS) neuropathy, pure motor CIDP, pure sensory CIDP including chronic immune sensory polyradiculopathy (CISP), and focal CIDP. These phenotypes are currently considered to be variants of CIDP, even if the possibility that they represent different demyelinating neuropathies cannot be fully excluded considering differences in their response to therapy. Several data support the role of the immune system in the pathogenesis of CIDP even if the precise targets and actors (antibodies and lymphocytes) of this immune response remain uncertain. Recent studies have shown that the therapeutic response may differ in patients with peculiar clinical presentations supporting the hypothesis that different pathogenetic mechanisms may underlie the heterogeneity of CIDP. The majority of patients with CIDP show improvement after immune therapies including corticosteroids, plasma exchange, and high-dose intravenous immunoglobulin (IVIg). It remains unclear why none of the other immune therapies that were reported to be variably effective in other immune disorders proved to be effective also in CIDP.

Safety of diphtheria, tetanus, acellular pertussis and inactivated poliovirus (DTaP-IPV) vaccine

BACKGROUND

In 2008, a diphtheria, tetanus, acellular pertussis, and inactivated poliovirus combined vaccine (DTaP-IPV) was licensed for use in children 4 through 6 years of age. While pre-licensure studies did not demonstrate significant safety concerns, the number vaccinated in these studies was not sufficient to examine the risk of uncommon but serious adverse events.

OBJECTIVE

To assess the risk of serious adverse events following DTaP-IPV vaccination.

METHODS

The study was conducted from January 2009 through September 2012 in the Vaccine Safety Datalink (VSD) project. In the VSD, electronic vaccination and encounter data are updated and aggregated weekly as part of ongoing surveillance activities. Based on previous reports and biologic plausibility, eight potential adverse events were monitored: meningitis/encephalitis; seizures; stroke; Guillain-Barré syndrome; Stevens-Johnson syndrome; anaphylaxis; serious allergic reactions other than anaphylaxis; and serious local reactions. Adverse event rates in DTaP-IPV recipients were compared to historical incidence rates in the VSD population prior to 2009. Sequential probability ratio testing was used to analyze the data on a weekly basis.

RESULTS

During the study period, 201,116 children received DTaP-IPV vaccine. Ninety-seven percent of DTaP-IPV recipients also received other vaccines on the same day, typically measles-mumps-rubella and varicella vaccines. There was no statistically significant increased risk of any of the eight pre-specified adverse events among DTaP-IPV recipients when compared to historical incidence rates.

CONCLUSIONS

In this safety surveillance study of more than 200,000 DTaP-IPV vaccine recipients, there was no evidence of increased risk for any of the pre-specified adverse events monitored. Continued surveillance of DTaP-IPV vaccine safety may be warranted to monitor for rare adverse events, such as Guillain-Barré syndrome.

Iatrogenic neurology

Iatrogenic disease is one of the most frequent causes of hospital admissions and constitutes a growing public health problem. The most common type of iatrogenic neurologic disease is pharmacologic, and the central and peripheral nervous systems are particularly vulnerable. Despite this, iatrogenic disease is generally overlooked as a differential diagnosis among neurologic patients. The clinical picture of pharmacologically mediated iatrogenic neurologic disease can range from mild to fatal. Common and uncommon forms of drug toxicity are comprehensively addressed in this chapter. While the majority of neurologic adverse effects are listed and referenced in the tables, the most relevant issues are further discussed in the text.

Distal acquired demyelinating symmetric neuropathy after vaccination

Neuropathy after vaccination is a rare event. Chronic immune-mediated polyneuropathy developing in the postvaccination period is distinctly unusual and not well described. Almost all such patients have been reported as having typical chronic inflammatory demyelinating polyneuropathy. Distal acquired demyelinating symmetric neuropathy, unlike classic chronic inflammatory demyelinating polyneuropathy, is characterized by distally predominant sensory symptoms with no or mild distal weakness. We describe the clinical, laboratory, and neurophysiological findings of 2 patients who developed distal acquired demyelinating symmetric neuropathy after vaccination. Immunomodulatory therapy led to clinical improvement in both cases. The literature is reviewed with attention to the clinical features of chronic immune-mediated neuropathies that follow vaccination.

Guillain-Barré syndrome after tetanus toxoid, reduced diphtheria toxoid and acellular pertussis vaccine: a case report

Introduction

The association of Guillain-Barré syndrome with vaccination has been described in the literature; it is infrequent and controversial. An association with swine influenza, influenza, hepatitis and tetanus vaccination has been documented in few case reports.

Case presentation

A 40-year-old Caucasian man sustained a small right temporal epidural hematoma and nondisplaced right skull fractures after a fall from a roof. He was managed conservatively; a tetanus toxoid, reduced diphtheria toxoid and acellular pertussis vaccine was administered and a week later he was discharged home. A few days after his discharge, he experienced weakness and numbness in his legs, which progressed to involve his arms. Three weeks after his initial fall, he was readmitted with quadriparesis. A lumbar puncture revealed a cerebrospinal fluid protein of 790 mg/dL and one white blood cell. We diagnosed Guillain-Barré syndrome. Our patient was treated with intravenous immunoglobulin. Three months later his muscle strength had improved, but he continued to have tingling in his hands and feet and used a walker intermittently.

Conclusion

To the best of our knowledge, this is the first case of Guillain-Barré syndrome to be reported in the English literature after administration of tetanus toxoid, reduced diphtheria toxoid and acellular pertussis vaccine.

Severe neuropathy after diphtheria-tetanus-pertussis vaccination in a child carrying a novel frame-shift mutation in the small heat-shock protein 27 gene

Mutations in small heat-shock protein 27 and small heat-shock protein 22 genes were found in association with Charcot-Marie-Tooth disease type 2 and distal hereditary motor neuropathy. We searched for mutations in small heat-shock protein 27 gene in an Italian family with peripheral neuropathy and intrafamilial phenotypic variability. A novel heterozygous frame-shift mutation c.476_477delCT was found while point mutations in most genes associated with hereditary neuropathies were ruled out. In the proband, who showed a severe early onset peripheral neuropathy, an independent pathogenetic effect on the peripheral nervous system secondary to the tetanus toxoid injection may be supposed. This is the first truncating nonsense mutation in the small heat-shock protein 27 gene identified so far and the clinical, neurophysiologic, and neuropathological findings are discussed.

Vaccines and Guillain-Barré syndrome

Guillain-Barré syndrome (GBS) is the leading cause of acute flaccid paralysis in developed countries and is characterized by various degrees of weakness, sensory abnormalities and autonomic dysfunction. Although the underlying aetiology and pathophysiology of GBS are not completely understood, it is broadly believed that immune stimulation plays a role in its pathogenesis. Thus, since vaccines have an effect on the immune system it is biologically plausible that immunizations may be associated with subsequent GBS. The objective of this article is to review the current body of evidence that either supports or does not support a causal, rather than just temporal, association between various vaccines and GBS, and to provide an evidence-based review of this issue. The scope of the article includes published reports that, regardless of method of case ascertainment, appeared in peer-reviewed literature between 1950 and 2008. Our review indicates that, with rare exceptions, associations between vaccines and GBS have been only temporal. There is little evidence to support a causal association with most vaccines. The evidence for a causal association is strongest for the swine influenza vaccine that was used in 1976-77. Studies of influenza vaccines used in subsequent years, however, have found small or no increased risk of GBS. Older formulations of rabies vaccine cultured in mammalian brain tissues have been found to have an increased risk of GBS, but newer formulations of rabies vaccine, derived from chick embryo cells, do not appear to be associated with GBS at a greater than expected rate. In an earlier review, the Institute of Medicine concluded that the evidence favoured a causal association between oral polio vaccine and tetanus toxoid-containing vaccines and GBS. However, recent evidence from large epidemiological studies and mass immunization campaigns in different countries found no correlation between oral polio vaccine or tetanus toxoid-containing vaccines and GBS. Spontaneous reports to the US Vaccine Adverse Events Reporting System shortly after the introduction of quadrivalent conjugated meningococcal vaccine (MCV4) raised concerns of a possible association with GBS. Comparisons with expected rates of GBS, however, were inconclusive for an increased risk, and lack of controlled epidemiological studies makes it difficult to draw conclusions about a causal association. For other vaccines, available data are based on isolated case reports or very small clusters temporally related to immunizations, and no conclusion about causality can be drawn. There are certain circumstances in which immunizing individuals, particularly those with a prior history of GBS, may require caution. However, the benefit of vaccines in preventing disease and decreasing morbidity and mortality, particularly for influenza, needs to be weighed against the potential risk of GBS.

An assessment of the safety of adolescent and adult tetanus-diphtheria-acellular pertussis (Tdap) vaccine, using active surveillance for adverse events in the Vaccine Safety Datalink

Using a new sequential analytic method, the safety of tetanus-diphtheria-acellular pertussis (Tdap) vaccine was monitored weekly among subjects aged 10-64 years during 2005-2008. Encephalopathy-encephalitis-meningitis, paralytic syndromes, seizures, cranial nerve disorders, and Guillain-Barré syndrome were selected as outcomes based on previous reports and biologic plausibility. The risk following Tdap was not significantly higher than the risk after Td. Statistical power was sufficient to detect a relative risk of 4-5 for Guillain-Barré syndrome and 1.5-2 for the other outcomes. This study provides reassurance that Tdap is similar in safety to Td regarding the outcomes studied and supports the viability of sequential analysis for post-licensure vaccine safety monitoring.

Travel medicine interventions and neurological disease

As a consequence of increased mobility worldwide, persons with underlying medical conditions set out on a journey more often than in the past. Among pre-existing medical conditions, some neurological diseases, including multiple sclerosis and other demyelinating diseases, Guillain-Barré syndrome and myasthenia gravis often create management problems to travel medicine practitioners. There is some concern that these conditions could be worsened either by naturally acquired infections or by some travel medicine interventions. The aim of this review is to suggest a practical approach to each of these conditions and to examine the feasibility and the impact of travel medicine interventions on the underlying disease.

A case of fatal progressive neuropathy. Delayed consequence of multiple bites of a non-venomous snake?

Neurotoxicity is a common feature of the acute syndrome of systemic snake envenomation. In this report a patient with delayed onset of neurological manifestations after multiple bites of a non-venomous snake is described. The neurological cascade consisted of segmental painful muscle spasms presented several days after the snake bites, which gradually subsided and within a month was followed by muscle weakness in the legs. The latter progressed to flaccid quadriplegia with additional respiratory and autonomic failure leading to death after total disease duration of 5.5 months. The possibility that this unique neurological syndrome of fatal progressive neuropathy could be caused by either tetanus or an immune reaction initiated by snakebites is discussed.

Pathogenesis of chronic inflammatory demyelinating polyradiculoneuropathy

The acute lesions of chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) consist of endoneurial foci of chemokine and chemokine receptor expression and T cell and macrophage activation. The myelin protein antigens, P2, P0, and PMP22, each induce experimental autoimmune neuritis in rodent models and might be autoantigens in CIDP. The strongest evidence incriminates P0, to which antibodies have been found in 20% of cases. Failure of regulatory T-cell mechanism is thought to underlie persistent or recurrent disease, differentiating CIDP from the acute inflammatory demyelinating polyradiculoneuropathy form of Guillain-Barré syndrome. Corticosteroids, intravenous immunoglobulin and plasma exchange each provide short term benefit but the possible long-term benefits of immunosuppressive drugs have yet to be confirmed in randomised, controlled trials.

Tétraplégie flasque après vaccination anti-tétanique

INTRODUCTION

Anti-tetanus vaccination is considered to be very safe. However complications such as mononevritis, multinevritis or even polyradiculonevritis can be encountered.

OBSERVATION

An 85-year-old man was admitted to our unit after a traffic accident caused by stroke. Seventy-two hours later the patient developed tetraplegia within a few hours, caused by neuropathy secondary to anti-tetanus vaccination.

DISCUSSION

In this elderly patient, the rapid onset and severe presentation of the tetraplegia as well as the past history of normal vaccination and the axonal form of the neuropathy could have led to a misdiagnosis of neuropathy after booster anti-tetanus vaccination. We first ruled out other possible diagnoses and then reviewed the possible mechanisms of neurological complications of vaccinations. These complications are probably underestimated in elderly hospitalized patients who receive a booster shot in the emergency department.

CONCLUSION

This report illustrates the importance of reconsidering the benefit/risk relationship of anti-tetanos vaccination.

Management of chronic inflammatory demyelinating polyradiculoneuropathy

This review briefly describes current concepts concerning the nosological status, pathogenesis and management of chronic inflammatory demyelinating polyradiculoneuropathy (CIDP). CIDP is an uncommon variable disorder of unknown but probably autoimmune aetiology. The commonest form of CIDP causes more or less symmetrical progressive or relapsing weakness affecting proximal and distal muscles. Against this background the review describes the short-term responses to corticosteroids, intravenous immunoglobulin (IVIg) and plasma exchange that have been confirmed in randomised trials. In the absence of better evidence about long-term efficacy, corticosteroids or IVIg are usually favoured because of convenience. Benefit following introduction of azathioprine, cyclophosphamide, cyclosporin, other immunosuppressive agents, and interferon-beta and -alpha has been reported but randomised trials are needed to confirm these benefits. In patients with pure motor CIDP and multifocal motor neuropathy, corticosteroids may cause worsening and IVIg is more likely to be effective. General measures to rehabilitate patients and manage symptoms, including foot drop, weak hands, fatigue and pain, are important.

Postvaccinal inflammatory neuropathy: peripheral nerve biopsy in 3 cases

Autoimmune inflammatory polyneuropathy (PN) can be triggered by vaccination. We report 3 such cases. A 36-year-old female nurse presented 15 days after a hepatitis B vaccination (HBV) with acute sensory disturbances in the lower limbs. She had severe ataxia but no weakness. Cerebrospinal fluid (CSF) protein level was 84 mg/100 mL, with 3 lymphocytes. A 66-year-old man presented 21 days after HBV with severe motor and sensory PN involving all 4 limbs. A 66-year-old man presented 15 days after a yellow fever vaccination with progressive motor and sensory PN involving all 4 limbs and bilateral facial paralysis. CSF protein level was 300 mg/100 mL, with 5 lymphocytes. Six weeks later, a tracheostomy was performed. In these 3 patients, the nerve deficits lasted for months. In each case, peripheral nerve biopsy showed KP1-positive histiocytes but no T-lymphocytes in the endoneurium. On ultrastructural examination, there was axonal degeneration in the first 2 cases; in case 2, a few myelinated fibers exhibited an intra-axonal macrophage but the myelin sheath was preserved. There was only 1 example of macrophage-associated demyelination in case 2, but these were numerous in case 3. It is likely that in the first 2 cases, an autoimmune reaction against some axonal or neuronal components was triggered by HBV. It induced an acute sensory ataxic PN in case 1 and an acute motor and sensory axonal neuropathy (AMSAN) in case 2. The third patient had a chronic inflammatory demyelinating PN, likely triggered by yellow fever vaccination.

Phenomenology and treatment of tremor disorders

Tremor is classified according to anatomic distribution among body parts, and by frequency and amplitude during rest, postural maintenance, movement, intention, and the performance of specific tasks. Key historical features include age at onset, progression over time, family history, exacerbating and remitting factors and behaviors, response to alcohol and medications, and additional neurological signs and symptoms. Accurate diagnosis is a critical factor in predicting the natural history and response to treatment.

Guillain-Barré syndrome after combined tetanus-diphtheria toxoid vaccination

Guillain-Barré syndrome (GBS), an acute inflammatory polyradiculoneuropathy, is often associated with an antecedent factor, such as an infection, surgery, systemic malignancy, or vaccination. The first case of GBS following a vaccination with combined tetanus-diphtheria toxoid is reported.

Relapsing acute encephalopathy: a complication of diphtheria-tetanus-poliomyelitis immunization in a young boy

Neurological complications of immunizations are rare. We report the case of relapsing acute encephalitis in a boy after two subsequent diphtheria-tetanus-poliomyelitis vaccinations. First the clinical signs were those of acute disseminated encephalitis. During the second episode, the boy experienced optic neuritis. Recovery was complete after both events. Because of the close temporal relationship of both these demyelinating episodes with the immunizations, we favour a cause and effect relationship.

CONCLUSION

The observation of a 7-year-old boy who developed relapsing acute encephalitis after two diphtheria-tetanus-poliomyelitis vaccinations and a similar case in the literature suggests that this neurological manifestation may occur as a very rare complication of diphtheria-tetanus-poliomyelitis vaccination.

Acute radiculomyelitis after antitetanus vaccination

Active or passive immunisation with vaccines or sera can cause lesions of immunomediated pathogenesis involving both the central (CNS) and the peripheral nervous system (PNS). Although very rare, the neurological complications described during antitetanus vaccinations almost exclusively affect the PNS, those affecting the CNS being even more rare. The authors report a case of transverse myelitis with a radicular component, which arose acutely following the administration of tetanus toxoid and had a partially favourable course.

Tetanus: pathophysiology, management, and prophylaxis

As tetanus has become a rare disease in the developed world, physicians have become less comfortable with its diagnosis and management. The extent of adequate antitetanus immunity in the adult population, especially the elderly, is waning, in great measure because primary care physicians have not made prophylaxis a priority in their routine encounters with patients. Furthermore, as the population of immunocompromised hosts grows, an increasing percentage of our patients may not respond to standard active immunization routines. Unless these trends are reversed, we face a substantial increase in the incidence of this dread disorder. Tetanus is also of interest as a relatively simple model of disordered motor control that can instruct us in the management of the many more common causes of neurogenic muscular rigidity. The toxin produced by Clostridium tetani finds increasing use in laboratories investigating brain function as well. Clinical tetanus is divided into four symptomatic types: generalized tetanus, local tetanus, cephalic tetanus, and neonatal tetanus. This monograph discusses the diagnostic aspects of each type of tetanus, its pathophysiology, diagnosis, differential diagnosis, and treatment. Preventing tetanus should be a high priority for all primary care physicians. Active immunization with tetanus toxoid is remarkably effective and safe. Passive immunization with human tetanus immune globulin is indicated in certain circumstances, which are discussed below.

Polyradiculoneuritis following botulinum toxin therapy

The development of Guillain-Barré syndrome is reported in a patient, who had previously received botulinum toxin type A injections into both orbicularis oculi muscles to treat idiopathic blepharospasm. The possibility of a causal relationship is discussed with consideration of the literature on adverse effects of vaccinations and of Clostridium botulinum and its toxin.

Adverse events following immunization: assessing probability of causation

The Monitoring System for Adverse Events Following Immunization of the Centers for Disease Control collects data on events temporally related to immunization. Occasionally, reports are received of neurologic disturbances temporally related to receipt of vaccine. Most of these disturbances are events that regularly occur in the absence of immunization. It is then difficult to determine whether the relationship between the immunization and illness is causal or coincidental. We developed a method to assess causation of serious neurologic events by probability theory. By combining epidemiologic information on disease incidence with specific elements of the patient history, an estimate of the odds of vaccine causation can be derived, based on rational assumptions rather than observer bias. The result is not a diagnosis but an estimate of probability.

Chronic experimental allergic neuritis in Lewis rats

An experimental chronic relapsing demyelinating neuropathy was produced by immunizing adult Lewis rats with bovine myelin in low (2.5 mg) and high (5 mg) doses, with and without Mycobacterium tuberculosis in the adjuvant. Each regime produced a similar disease course: acute severe hind limb weakness was followed by apparent recovery and then reappearance of mild neurological deficit with occasional spontaneous exacerbations. The partially recovered animals were relatively resistant to reimmunization with myelin. Immunization of four-week-old rats with myelin in complete adjuvant produced disease with a similar course. Subsequent immunization of these juvenile rats with adjuvant alone precipitated exacerbations. In the late stages, the prominent changes in peripheral nerves and nerve roots were axon loss, axonal regeneration and remyelination while inflammatory cell infiltration was confined to occasional foci. Onion bulb formation was extremely common in the dorsal root ganglia and affected in particular the nerve fibres close to the dorsal root ganglion cells. The cells forming the onion bulbs resembled the satellite cells surrounding the axon hillocks. Onion bulb formation also occurred in the portion of the ventral roots adjacent to the dorsal root ganglion but was rare elsewhere. Immunocytochemistry revealed only occasional lymphocyte infiltration but there was increased Class I and Class II MHC antigen expression throughout the peripheral nervous system. The results are relevant to the interpretation of biopsies from patients with chronic demyelinating neuropathy of possible inflammatory or autoimmune origin.

Chronic recurrent Guillain-Barré syndrome: report of 3 cases

The classical Guillain-Barré syndrome is an acute or subacute polyradiculo-neuropathy whose main clinical features are progressive weakness of the limbs, decrease or absence of tendon reflexes, and sensory changes. Although in most of the cases there is complete recovery in weeks or months, some patients have a slow and progressive relapsing course and present thickening of the peripheral nerves. In this paper we describe three cases of the chronic and relapsing variety of Guillain-Barré syndrome, two of which had prominent hypertrophic changes in the peripheral nerves with onion bulb formations. The clinical and pathological features of this disease are reviewed. The three patients improved with the use of steroids.

Pertussis: the disease and the vaccine

Pertussis is a serious respiratory disease in infants. Immunization prevents infection in some; in others it permits infection but prevents disease. Epidemics occur when immunization rates fall. Whole-cell vaccine has proved to be a safe and effective method of disease control. Whole-cell vaccines have been used because the bacterial components responsible for immunity have not been identified. New component vaccines have not been licensed in the United States because they do not meet standards for efficacy. Whole-cell pertussis vaccine has been associated with febrile and afebrile seizures which are generalized and occur within 72 hours of immunization. Permanent brain damage caused by pertussis vaccine is rare. One study suggested a risk of 1:310,000 immunizations which is not precise and probably excessive; however, even using this figure, the risk-benefit ratio for 3 immunizations is favorable when compared to the risks of the natural disease. Child neurologists should recommended immunization for brain damaged infants with static or chronic brain syndromes. Pertussis immunization should be delayed or omitted when the neurologic status is unclear.