1
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Bellanti R, Rinaldi S. Guillain-Barré syndrome: A comprehensive review. Eur J Neurol 2024:e16365. [PMID: 38813755 DOI: 10.1111/ene.16365] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2024] [Revised: 05/12/2024] [Accepted: 05/13/2024] [Indexed: 05/31/2024]
Abstract
Guillain-Barré syndrome (GBS) is a potentially devastating yet treatable disorder. A classically postinfectious, immune-mediated, monophasic polyradiculoneuropathy, it is the leading global cause of acquired neuromuscular paralysis. In most cases, the immunopathological process driving nerve injury is ill-defined. Diagnosis of GBS relies on clinical features, supported by laboratory findings and electrophysiology. Although previously divided into primary demyelinating or axonal variants, this dichotomy is increasingly challenged, and is not endorsed by the recent European Academy of Neurology (EAN)/Peripheral Nerve Society (PNS) guidelines. Intravenous immunoglobulin and plasma exchange remain the primary modalities of treatment, regardless of the electrophysiological subtype. Most patients recover, but approximately one-third require mechanical ventilation, and 5% die. Disease activity and treatment response are currently monitored through interval neurological examination and outcome measures, and the potential role of fluid biomarkers is under ongoing scrutiny. Novel potential therapies for GBS are being explored but none have yet modified clinical practice. This review provides a comprehensive update on the pathological and clinical aspects of GBS for clinicians and scientists.
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Affiliation(s)
- Roberto Bellanti
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Simon Rinaldi
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
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2
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van Doorn PA, Van den Bergh PYK, Hadden RDM, Avau B, Vankrunkelsven P, Attarian S, Blomkwist-Markens PH, Cornblath DR, Goedee HS, Harbo T, Jacobs BC, Kusunoki S, Lehmann HC, Lewis RA, Lunn MP, Nobile-Orazio E, Querol L, Rajabally YA, Umapathi T, Topaloglu HA, Willison HJ. European Academy of Neurology/Peripheral Nerve Society Guideline on diagnosis and treatment of Guillain-Barré syndrome. Eur J Neurol 2023; 30:3646-3674. [PMID: 37814552 DOI: 10.1111/ene.16073] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Revised: 08/25/2023] [Accepted: 08/28/2023] [Indexed: 10/11/2023]
Abstract
Guillain-Barré syndrome (GBS) is an acute polyradiculoneuropathy. Symptoms may vary greatly in presentation and severity. Besides weakness and sensory disturbances, patients may have cranial nerve involvement, respiratory insufficiency, autonomic dysfunction and pain. To develop an evidence-based guideline for the diagnosis and treatment of GBS, using Grading of Recommendations, Assessment, Development and Evaluation (GRADE) methodology a Task Force (TF) of the European Academy of Neurology (EAN) and the Peripheral Nerve Society (PNS) constructed 14 Population/Intervention/Comparison/Outcome questions (PICOs) covering diagnosis, treatment and prognosis of GBS, which guided the literature search. Data were extracted and summarised in GRADE Summaries of Findings (for treatment PICOs) or Evidence Tables (for diagnostic and prognostic PICOs). Statements were prepared according to GRADE Evidence-to-Decision (EtD) frameworks. For the six intervention PICOs, evidence-based recommendations are made. For other PICOs, good practice points (GPPs) are formulated. For diagnosis, the principal GPPs are: GBS is more likely if there is a history of recent diarrhoea or respiratory infection; CSF examination is valuable, particularly when the diagnosis is less certain; electrodiagnostic testing is advised to support the diagnosis; testing for anti-ganglioside antibodies is of limited clinical value in most patients with typical motor-sensory GBS, but anti-GQ1b antibody testing should be considered when Miller Fisher syndrome (MFS) is suspected; nodal-paranodal antibodies should be tested when autoimmune nodopathy is suspected; MRI or ultrasound imaging should be considered in atypical cases; and changing the diagnosis to acute-onset chronic inflammatory demyelinating polyradiculoneuropathy (A-CIDP) should be considered if progression continues after 8 weeks from onset, which occurs in around 5% of patients initially diagnosed with GBS. For treatment, the TF recommends intravenous immunoglobulin (IVIg) 0.4 g/kg for 5 days, in patients within 2 weeks (GPP also within 2-4 weeks) after onset of weakness if unable to walk unaided, or a course of plasma exchange (PE) 12-15 L in four to five exchanges over 1-2 weeks, in patients within 4 weeks after onset of weakness if unable to walk unaided. The TF recommends against a second IVIg course in GBS patients with a poor prognosis; recommends against using oral corticosteroids, and weakly recommends against using IV corticosteroids; does not recommend PE followed immediately by IVIg; weakly recommends gabapentinoids, tricyclic antidepressants or carbamazepine for treatment of pain; does not recommend a specific treatment for fatigue. To estimate the prognosis of individual patients, the TF advises using the modified Erasmus GBS outcome score (mEGOS) to assess outcome, and the modified Erasmus GBS Respiratory Insufficiency Score (mEGRIS) to assess the risk of requiring artificial ventilation. Based on the PICOs, available literature and additional discussions, we provide flow charts to assist making clinical decisions on diagnosis, treatment and the need for intensive care unit admission.
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Affiliation(s)
- Pieter A van Doorn
- Department of Neurology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Peter Y K Van den Bergh
- Neuromuscular Reference Centre, Department of Neurology, University Hospital Saint-Luc, Brussels, Belgium
| | | | - Bert Avau
- Cochrane Belgium, CEBAM, Leuven, Belgium
- CEBaP, Belgian Red Cross, Mechelen, Belgium
| | - Patrik Vankrunkelsven
- Department of Public Health and Primary Care KU Leuven, Cochrane Belgium, CEBAM, Leuven, Belgium
| | - Shahram Attarian
- Centre de Référence des Maladies Neuromusculaires et de la SLA, APHM, CHU Timone, Marseille, France
| | | | - David R Cornblath
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - H Stephan Goedee
- Department of Neurology, University Medical Center Utrecht, Brain Center UMC Utrecht, Utrecht, The Netherlands
| | - Thomas Harbo
- Department of Neurology, Aarhus University Hospital, Aarhus, Denmark
| | - Bart C Jacobs
- Department of Neurology and Immunology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Susumu Kusunoki
- Department of Neurology, Faculty of Medicine, Kindai University, Osaka, Japan
| | - Helmar C Lehmann
- Department of Neurology, Medical Faculty Köln, University Hospital Köln, Cologne, Germany
| | - Richard A Lewis
- Department of Neurology, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Michael P Lunn
- Department of Neurology and MRC Centre for Neuromuscular Diseases, National Hospital for Neurology and Neurosurgery, London, UK
| | - Eduardo Nobile-Orazio
- Neuromuscular and Neuroimmunology Service, IRCCS Humanitas Research Institute, Department of Medical Biotechnology and Translational Medicine, University of Milan, Milan, Italy
| | - Luis Querol
- Neuromuscular Diseases Unit, Neurology Department, Hospital de la Santa Creu I Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Yusuf A Rajabally
- Neuromuscular Service, Neurology, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | | | | | - Hugh J Willison
- Glasgow Biomedical Research Centre, University of Glasgow, Glasgow, UK
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3
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van Doorn PA, Van den Bergh PYK, Hadden RDM, Avau B, Vankrunkelsven P, Attarian S, Blomkwist-Markens PH, Cornblath DR, Goedee HS, Harbo T, Jacobs BC, Kusunoki S, Lehmann HC, Lewis RA, Lunn MP, Nobile-Orazio E, Querol L, Rajabally YA, Umapathi T, Topaloglu HA, Willison HJ. European Academy of Neurology/Peripheral Nerve Society Guideline on diagnosis and treatment of Guillain-Barré syndrome. J Peripher Nerv Syst 2023; 28:535-563. [PMID: 37814551 DOI: 10.1111/jns.12594] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Revised: 08/25/2023] [Accepted: 08/28/2023] [Indexed: 10/11/2023]
Abstract
Guillain-Barré syndrome (GBS) is an acute polyradiculoneuropathy. Symptoms may vary greatly in presentation and severity. Besides weakness and sensory disturbances, patients may have cranial nerve involvement, respiratory insufficiency, autonomic dysfunction and pain. To develop an evidence-based guideline for the diagnosis and treatment of GBS, using Grading of Recommendations, Assessment, Development and Evaluation (GRADE) methodology, a Task Force (TF) of the European Academy of Neurology (EAN) and the Peripheral Nerve Society (PNS) constructed 14 Population/Intervention/Comparison/Outcome questions (PICOs) covering diagnosis, treatment and prognosis of GBS, which guided the literature search. Data were extracted and summarised in GRADE Summaries of Findings (for treatment PICOs) or Evidence Tables (for diagnostic and prognostic PICOs). Statements were prepared according to GRADE Evidence-to-Decision (EtD) frameworks. For the six intervention PICOs, evidence-based recommendations are made. For other PICOs, good practice points (GPPs) are formulated. For diagnosis, the principal GPPs are: GBS is more likely if there is a history of recent diarrhoea or respiratory infection; CSF examination is valuable, particularly when the diagnosis is less certain; electrodiagnostic testing is advised to support the diagnosis; testing for anti-ganglioside antibodies is of limited clinical value in most patients with typical motor-sensory GBS, but anti-GQ1b antibody testing should be considered when Miller Fisher syndrome (MFS) is suspected; nodal-paranodal antibodies should be tested when autoimmune nodopathy is suspected; MRI or ultrasound imaging should be considered in atypical cases; and changing the diagnosis to acute-onset chronic inflammatory demyelinating polyradiculoneuropathy (A-CIDP) should be considered if progression continues after 8 weeks from onset, which occurs in around 5% of patients initially diagnosed with GBS. For treatment, the TF recommends intravenous immunoglobulin (IVIg) 0.4 g/kg for 5 days, in patients within 2 weeks (GPP also within 2-4 weeks) after onset of weakness if unable to walk unaided, or a course of plasma exchange (PE) 12-15 L in four to five exchanges over 1-2 weeks, in patients within 4 weeks after onset of weakness if unable to walk unaided. The TF recommends against a second IVIg course in GBS patients with a poor prognosis; recommends against using oral corticosteroids, and weakly recommends against using IV corticosteroids; does not recommend PE followed immediately by IVIg; weakly recommends gabapentinoids, tricyclic antidepressants or carbamazepine for treatment of pain; does not recommend a specific treatment for fatigue. To estimate the prognosis of individual patients, the TF advises using the modified Erasmus GBS outcome score (mEGOS) to assess outcome, and the modified Erasmus GBS Respiratory Insufficiency Score (mEGRIS) to assess the risk of requiring artificial ventilation. Based on the PICOs, available literature and additional discussions, we provide flow charts to assist making clinical decisions on diagnosis, treatment and the need for intensive care unit admission.
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Affiliation(s)
- Pieter A van Doorn
- Department of Neurology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Peter Y K Van den Bergh
- Neuromuscular Reference Centre, Department of Neurology, University Hospital Saint-Luc, Brussels, Belgium
| | | | - Bert Avau
- Cochrane Belgium, CEBAM, Leuven, Belgium
- CEBaP, Belgian Red Cross, Mechelen, Belgium
| | - Patrik Vankrunkelsven
- Department of Public Health and Primary Care KU Leuven, Cochrane Belgium, CEBAM, Leuven, Belgium
| | - Shahram Attarian
- Centre de Référence des Maladies Neuromusculaires et de la SLA, APHM, CHU Timone, Marseille, France
| | | | - David R Cornblath
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - H Stephan Goedee
- Department of Neurology, University Medical Center Utrecht, Brain Center UMC Utrecht, Utrecht, The Netherlands
| | - Thomas Harbo
- Department of Neurology, Aarhus University Hospital, Aarhus, Denmark
| | - Bart C Jacobs
- Department of Neurology and Immunology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Susumu Kusunoki
- Department of Neurology, Faculty of Medicine, Kindai University, Osaka, Japan
| | - Helmar C Lehmann
- Department of Neurology, Medical Faculty Köln, University Hospital Köln, Cologne, Germany
| | - Richard A Lewis
- Department of Neurology, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Michael P Lunn
- Department of Neurology and MRC Centre for Neuromuscular Diseases, National Hospital for Neurology and Neurosurgery, London, UK
| | - Eduardo Nobile-Orazio
- Neuromuscular and Neuroimmunology Service, IRCCS Humanitas Research Institute, Department of Medical Biotechnology and Translational Medicine, University of Milan, Milan, Italy
| | - Luis Querol
- Neuromuscular Diseases Unit, Neurology Department, Hospital de la Santa Creu I Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Yusuf A Rajabally
- Neuromuscular Service, Neurology, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | | | | | - Hugh J Willison
- Glasgow Biomedical Research Centre, University of Glasgow, Glasgow, UK
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Shastri A, Al Aiyan A, Kishore U, Farrugia ME. Immune-Mediated Neuropathies: Pathophysiology and Management. Int J Mol Sci 2023; 24:7288. [PMID: 37108447 PMCID: PMC10139406 DOI: 10.3390/ijms24087288] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2022] [Revised: 03/12/2023] [Accepted: 03/21/2023] [Indexed: 04/29/2023] Open
Abstract
Dysfunction of the immune system can result in damage of the peripheral nervous system. The immunological mechanisms, which include macrophage infiltration, inflammation and proliferation of Schwann cells, result in variable degrees of demyelination and axonal degeneration. Aetiology is diverse and, in some cases, may be precipitated by infection. Various animal models have contributed and helped to elucidate the pathophysiological mechanisms in acute and chronic inflammatory polyradiculoneuropathies (Guillain-Barre Syndrome and chronic inflammatory demyelinating polyradiculoneuropathy, respectively). The presence of specific anti-glycoconjugate antibodies indicates an underlying process of molecular mimicry and sometimes assists in the classification of these disorders, which often merely supports the clinical diagnosis. Now, the electrophysiological presence of conduction blocks is another important factor in characterizing another subgroup of treatable motor neuropathies (multifocal motor neuropathy with conduction block), which is distinct from Lewis-Sumner syndrome (multifocal acquired demyelinating sensory and motor neuropathy) in its response to treatment modalities as well as electrophysiological features. Furthermore, paraneoplastic neuropathies are also immune-mediated and are the result of an immune reaction to tumour cells that express onconeural antigens and mimic molecules expressed on the surface of neurons. The detection of specific paraneoplastic antibodies often assists the clinician in the investigation of an underlying, sometimes specific, malignancy. This review aims to discuss the immunological and pathophysiological mechanisms that are thought to be crucial in the aetiology of dysimmune neuropathies as well as their individual electrophysiological characteristics, their laboratory features and existing treatment options. Here, we aim to present a balance of discussion from these diverse angles that may be helpful in categorizing disease and establishing prognosis.
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Affiliation(s)
- Abhishek Shastri
- Central and North West London NHS Foundation Trust, London NW1 3AX, UK
| | - Ahmad Al Aiyan
- Department of Veterinary Medicine, UAE University, Al Ain P.O. Box 15551, United Arab Emirates
| | - Uday Kishore
- Department of Veterinary Medicine, UAE University, Al Ain P.O. Box 15551, United Arab Emirates
| | - Maria Elena Farrugia
- Department of Neurology, Institute of Neurological Sciences, Southern General Hospital, Glasgow G51 4TF, UK
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Landscape of Guillain-Barré Syndrome Interventional Clinical Trials. J Clin Neuromuscul Dis 2023; 24:119-129. [PMID: 36809199 DOI: 10.1097/cnd.0000000000000441] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/23/2023]
Abstract
INTRODUCTION Guillain-Barré syndrome (GBS) is an immune-mediated polyradiculoneuropathy that remains a debilitating disease despite medical treatment. Numerous challenges still exist, including the development of disease-modifying therapies that can improve prognosis, particularly in patients with poor prognostic outcomes. In this study, we explored clinical trials related to GBS, analyzed the trial characteristics, suggested some ideas for improvement, and discussed recent advances. METHODS On December 30, 2021, the authors searched ClinicalTrials.gov for all interventional and therapeutic clinical trials related to GBS, without any restrictions on the date or location. Trial characteristics including trial duration, location, phase, sample size, and publications were retrieved and analyzed. RESULTS Twenty-one trials fulfilled the selection criteria. Clinical trials were conducted in 11 different countries, most of them occurring in Asia. On average, the trial duration across the phases was around 2 years. About two-thirds of trials were completed, and 39% of trials were in the early phases (1 and 2). Only 24% of all trials and 60% of completed trials have publications in this study. CONCLUSIONS The study revealed a low number of trials, lack of geographic diversity, scanty enrollment of patients, and paucity of clinical trial duration and publications regarding GBS clinical trials. Optimization of GBS trials is fundamental to achieving effective therapies for this disease.
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McGonigal R, Cunningham ME, Smyth D, Chou M, Barrie JA, Wilkie A, Campbell C, Saatman KE, Lunn M, Willison HJ. The endogenous calpain inhibitor calpastatin attenuates axon degeneration in murine Guillain-Barré syndrome. J Peripher Nerv Syst 2023; 28:4-16. [PMID: 36335586 PMCID: PMC10947122 DOI: 10.1111/jns.12520] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Revised: 10/24/2022] [Accepted: 10/30/2022] [Indexed: 11/08/2022]
Abstract
Axon degeneration accounts for the poor clinical outcome in Guillain-Barré syndrome (GBS), yet no treatments target this key pathogenic stage. Animal models demonstrate anti-ganglioside antibodies (AGAb) induce axolemmal complement pore formation through which calcium flux activates the intra-axonal calcium-dependent proteases, calpains. We previously showed protection of axonal components using soluble calpain inhibitors in ex vivo GBS mouse models, and herein, we assess the potential of axonally-restricted calpain inhibition as a neuroprotective therapy operating in vivo. Using transgenic mice that over-express the endogenous human calpain inhibitor calpastatin (hCAST) neuronally, we assessed distal motor nerve integrity in our established GBS models. We induced immune-mediated injury with monoclonal AGAb plus a source of human complement. The calpain substrates neurofilament and AnkyrinG, nerve structural proteins, were assessed by immunolabelling and in the case of neurofilament, by single-molecule arrays (Simoa). As the distal intramuscular portion of the phrenic nerve is prominently targeted in our in vivo model, respiratory function was assessed by whole-body plethysmography as the functional output in the acute and extended models. hCAST expression protects distal nerve structural integrity both ex and in vivo, as shown by attenuation of neurofilament breakdown by immunolabelling and Simoa. In an extended in vivo model, while mice still initially undergo respiratory distress owing to acute conduction failure, the recovery phase was accelerated by hCAST expression. Axonal calpain inhibition can protect the axonal integrity of the nerve in an in vivo GBS paradigm and hasten recovery. These studies reinforce the strong justification for developing further animal and human clinical studies using exogenous calpain inhibitors.
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Affiliation(s)
- Rhona McGonigal
- School of Infection & ImmunityUniversity of GlasgowGlasgowUnited Kingdom
| | | | - Duncan Smyth
- National Hospital for Neurology and Neurosurgery, Centre for Neuromuscular DiseasesUniversity College LondonLondonUnited Kingdom
| | - Michael Chou
- National Hospital for Neurology and Neurosurgery, Centre for Neuromuscular DiseasesUniversity College LondonLondonUnited Kingdom
| | - Jennifer A. Barrie
- School of Infection & ImmunityUniversity of GlasgowGlasgowUnited Kingdom
| | - Andrew Wilkie
- School of Infection & ImmunityUniversity of GlasgowGlasgowUnited Kingdom
| | - Clare Campbell
- School of Infection & ImmunityUniversity of GlasgowGlasgowUnited Kingdom
| | - Kathryn E. Saatman
- Department of Physiology, Spinal Cord and Brain Injury Research CenterUniversity of KentuckyLexingtonKYUSA
| | - Michael Lunn
- National Hospital for Neurology and Neurosurgery, Centre for Neuromuscular DiseasesUniversity College LondonLondonUnited Kingdom
| | - Hugh J. Willison
- School of Infection & ImmunityUniversity of GlasgowGlasgowUnited Kingdom
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Kohle F, Dalakas MC, Lehmann HC. Repurposing MS immunotherapies for CIDP and other autoimmune neuropathies: unfulfilled promise or efficient strategy? Ther Adv Neurol Disord 2023; 16:17562864221137129. [PMID: 36620728 PMCID: PMC9810996 DOI: 10.1177/17562864221137129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2022] [Accepted: 10/19/2022] [Indexed: 01/03/2023] Open
Abstract
Despite advances in the treatment of chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) and other common autoimmune neuropathies (AN), still-many patients with these diseases do not respond satisfactorily to the available treatments. Repurposing of disease-modifying therapies (DMTs) from other autoimmune conditions, particularly multiple sclerosis (MS) and neuromyelitis optica spectrum disorders (NMOSD), is a promising strategy that may accelerate the establishment of novel treatment choices for AN. This approach appears attractive due to homologies in the pathogenesis of these diseases and the extensive post-marketing experience that has been gathered from treating MS and NMOSD patients. The idea is also strengthened by a number of studies that explored the efficacy of DMTs in animal models of AN but also in some CIDP patients. We here review the available preclinical and clinical data of approved MS therapeutics in terms of their applicability to AN, especially CIDP. Promising therapeutic approaches appear to be B cell-directed and complement-targeting strategies, such as anti-CD20/anti-CD19 agents, Bruton's tyrosine kinase inhibitors and anti-C5 agents, as they exert their effects in the periphery. This is a major advantage because, in contrast to MS, their action in the periphery is sufficient to exert significant immunomodulation.
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Affiliation(s)
- Felix Kohle
- Department of Neurology, Faculty of Medicine,
University of Cologne and University Hospital Cologne, Cologne,
Germany
| | - Marinos C. Dalakas
- Department of Neurology, Thomas Jefferson
University, Philadelphia, PA, USA,Neuroimmunology Unit, National and Kapodistrian
University of Athens Medical School, Athens, Greece
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Campbell CI, McGonigal R, Barrie JA, Delaere J, Bracke L, Cunningham ME, Yao D, Delahaye T, Van de Walle I, Willison HJ. Complement inhibition prevents glial nodal membrane injury in a GM1 antibody-mediated mouse model. Brain Commun 2022; 4:fcac306. [PMID: 36523267 PMCID: PMC9746686 DOI: 10.1093/braincomms/fcac306] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Revised: 09/09/2022] [Accepted: 11/21/2022] [Indexed: 11/25/2022] Open
Abstract
The involvement of the complement pathway in Guillain-Barré syndrome pathogenesis has been demonstrated in both patient biosamples and animal models. One proposed mechanism is that anti-ganglioside antibodies mediate neural membrane injury through the activation of complement and the formation of membrane attack complex pores, thereby allowing the uncontrolled influx of ions, including calcium, intracellularly. Calcium influx activates the calcium-dependent protease calpain, leading to the cleavage of neural cytoskeletal and transmembrane proteins and contributing to subsequent functional failure. Complement inhibition has been demonstrated to provide effective protection from injury in anti-ganglioside antibody-mediated mouse models of axonal variants of Guillain-Barré syndrome; however, the role of complement in the pathogenesis of demyelinating variants has yet to be established. Thus, it is currently unknown whether complement inhibition would be an effective therapeutic for Guillain-Barré syndrome patients with injuries to the Schwann cell membrane. To address this, we recently developed a mouse model whereby the Schwann cell membrane was selectively targeted with an anti-GM1 antibody resulting in significant disruption to the axo-glial junction and cytoplasmic paranodal loops, presenting as conduction block. Herein, we utilize this Schwann cell nodal membrane injury model to determine the relevance of inhibiting complement activation. We addressed the early complement component C2 as the therapeutic target within the complement cascade by using the anti-C2 humanized monoclonal antibody, ARGX-117. This anti-C2 antibody blocks the formation of C3 convertase, specifically inhibiting the classical and lectin complement pathways and preventing the production of downstream harmful anaphylatoxins (C3a and C5a) and membrane attack complexes. Here, we demonstrate that C2 inhibition significantly attenuates injury to paranodal proteins at the node of Ranvier and improves respiratory function in ex vivo and in vivo Schwann cell nodal membrane injury models. In parallel studies, C2 inhibition also protects axonal integrity in our well-established model of acute motor axonal neuropathy mediated by both mouse and human anti-GM1 antibodies. These data demonstrate that complement inhibition prevents injury in a Schwann cell nodal membrane injury model, which is representative of neuropathies associated with anti-GM1 antibodies, including Guillain-Barré syndrome and multifocal motor neuropathy. This outcome suggests that both the motor axonal and demyelinating variants of Guillain-Barré syndrome should be included in future complement inhibition clinical trials.
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Affiliation(s)
- Clare I Campbell
- Institute of Infection, Immunity and Inflammation, University of Glasgow, Glasgow G12 8TA, UK
| | - Rhona McGonigal
- Institute of Infection, Immunity and Inflammation, University of Glasgow, Glasgow G12 8TA, UK
| | - Jennifer A Barrie
- Institute of Infection, Immunity and Inflammation, University of Glasgow, Glasgow G12 8TA, UK
| | | | | | - Madeleine E Cunningham
- Institute of Infection, Immunity and Inflammation, University of Glasgow, Glasgow G12 8TA, UK
| | - Denggao Yao
- Institute of Infection, Immunity and Inflammation, University of Glasgow, Glasgow G12 8TA, UK
| | | | | | - Hugh J Willison
- Correspondence to: Hugh J. Willison University of Glasgow, Institute of Infection Immunity and Inflammation, Sir Graeme Davis Building University Place, Glasgow G12 8TA, UK E-mail:
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9
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Jennings MJ, Kagiava A, Vendredy L, Spaulding EL, Stavrou M, Hathazi D, Grüneboom A, De Winter V, Gess B, Schara U, Pogoryelova O, Lochmüller H, Borchers CH, Roos A, Burgess RW, Timmerman V, Kleopa KA, Horvath R. NCAM1 and GDF15 are biomarkers of Charcot-Marie-Tooth disease in patients and mice. Brain 2022; 145:3999-4015. [PMID: 35148379 PMCID: PMC9679171 DOI: 10.1093/brain/awac055] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Revised: 11/22/2021] [Accepted: 12/15/2021] [Indexed: 02/02/2023] Open
Abstract
Molecular markers scalable for clinical use are critical for the development of effective treatments and the design of clinical trials. Here, we identify proteins in sera of patients and mouse models with Charcot-Marie-Tooth disease (CMT) with characteristics that make them suitable as biomarkers in clinical practice and therapeutic trials. We collected serum from mouse models of CMT1A (C61 het), CMT2D (GarsC201R, GarsP278KY), CMT1X (Gjb1-null), CMT2L (Hspb8K141N) and from CMT patients with genotypes including CMT1A (PMP22d), CMT2D (GARS), CMT2N (AARS) and other rare genetic forms of CMT. The severity of neuropathy in the patients was assessed by the CMT Neuropathy Examination Score (CMTES). We performed multitargeted proteomics on both sample sets to identify proteins elevated across multiple mouse models and CMT patients. Selected proteins and additional potential biomarkers, such as growth differentiation factor 15 (GDF15) and cell free mitochondrial DNA, were validated by ELISA and quantitative PCR, respectively. We propose that neural cell adhesion molecule 1 (NCAM1) is a candidate biomarker for CMT, as it was elevated in Gjb1-null, Hspb8K141N, GarsC201R and GarsP278KY mice as well as in patients with both demyelinating (CMT1A) and axonal (CMT2D, CMT2N) forms of CMT. We show that NCAM1 may reflect disease severity, demonstrated by a progressive increase in mouse models with time and a significant positive correlation with CMTES neuropathy severity in patients. The increase in NCAM1 may reflect muscle regeneration triggered by denervation, which could potentially track disease progression or the effect of treatments. We found that member proteins of the complement system were elevated in Gjb1-null and Hspb8K141N mouse models as well as in patients with both demyelinating and axonal CMT, indicating possible complement activation at the impaired nerve terminals. However, complement proteins did not correlate with the severity of neuropathy measured on the CMTES scale. Although the complement system does not seem to be a prognostic biomarker, we do show complement elevation to be a common disease feature of CMT, which may be of interest as a therapeutic target. We also identify serum GDF15 as a highly sensitive diagnostic biomarker, which was elevated in all CMT genotypes as well as in Hspb8K141N, Gjb1-null, GarsC201R and GarsP278KY mouse models. Although we cannot fully explain its origin, it may reflect increased stress response or metabolic disturbances in CMT. Further large and longitudinal patient studies should be performed to establish the value of these proteins as diagnostic and prognostic molecular biomarkers for CMT.
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Affiliation(s)
- Matthew J Jennings
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Alexia Kagiava
- Department of Neuroscience and Neuromuscular Disorders Centre, The Cyprus Institute of Neurology and Genetics, Nicosia, Cyprus
| | - Leen Vendredy
- Peripheral Neuropathy Research Group, Department of Biomedical Sciences, Institute Born Bunge, University of Antwerp, Antwerp, Belgium
| | - Emily L Spaulding
- The Jackson Laboratory, Bar Harbor, ME, USA
- Graduate School of Biomedical Sciences and Engineering, University of Maine, Orono, ME 04469, USA
| | - Marina Stavrou
- Department of Neuroscience and Neuromuscular Disorders Centre, The Cyprus Institute of Neurology and Genetics, Nicosia, Cyprus
| | - Denisa Hathazi
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Anika Grüneboom
- Leibniz-Institut für Analytische Wissenschaften—ISAS—e.V, Dortmund, Germany
| | - Vicky De Winter
- Peripheral Neuropathy Research Group, Department of Biomedical Sciences, Institute Born Bunge, University of Antwerp, Antwerp, Belgium
| | - Burkhard Gess
- Department of Neurology, University Hospital Aachen, Aachen, Germany
| | - Ulrike Schara
- Centre for Neuromuscular Disorders in Children, University of Duisburg-Essen, Essen, Germany
| | - Oksana Pogoryelova
- Directorate of Neurosciences, Royal Victoria Infirmary, Newcastle upon Tyne Hospitals, NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Hanns Lochmüller
- Division of Neurology, Department of Medicine, The Ottawa Hospital, Brain and Mind Research Institute and Children’s Hospital of Eastern Ontario Research Institute, University of Ottawa, Ottawa, Canada
- Department of Neuropediatrics and Muscle Disorders, Medical Center–University of Freiburg, Faculty of Medicine, Freiburg, Germany
- CNAG-CRG, Centre for Genomic Regulation, Barcelona Institute of Science and Technology, Barcelona, Spain
| | - Christoph H Borchers
- Segal Cancer Proteomics Centre, Lady Davis Institute, Jewish General Hospital, McGill University, Montreal, Quebec, Canada
- Gerald Bronfman Department of Oncology, Jewish General Hospital, McGill University, Montreal, Quebec, Canada
- Center for Computational and Data-Intensive Science and Engineering, Skolkovo Institute of Science and Technology, Moscow, Russia
| | - Andreas Roos
- Division of Neurology, Department of Medicine, The Ottawa Hospital, Brain and Mind Research Institute and Children’s Hospital of Eastern Ontario Research Institute, University of Ottawa, Ottawa, Canada
- Department of Neurology, Heimer Institute for Muscle Research, University Hospital Bergmannsheil, Ruhr University Bochum, Bochum, Germany
| | - Robert W Burgess
- The Jackson Laboratory, Bar Harbor, ME, USA
- Graduate School of Biomedical Sciences and Engineering, University of Maine, Orono, ME 04469, USA
| | - Vincent Timmerman
- Peripheral Neuropathy Research Group, Department of Biomedical Sciences, Institute Born Bunge, University of Antwerp, Antwerp, Belgium
| | - Kleopas A Kleopa
- Department of Neuroscience and Neuromuscular Disorders Centre, The Cyprus Institute of Neurology and Genetics, Nicosia, Cyprus
| | - Rita Horvath
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
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10
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Therapies in Autoimmune Peripheral Neuropathies beyond Intravenous Immunoglobulin, Plasma Exchange and Corticosteroids: An Analytical Review. Transfus Med Rev 2022; 36:220-229. [DOI: 10.1016/j.tmrv.2022.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2022] [Revised: 05/26/2022] [Accepted: 05/27/2022] [Indexed: 11/20/2022]
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11
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Meidaninikjeh S, Sabouni N, Taheri M, Borjkhani M, Bengar S, Majidi Zolbanin N, Khalili A, Jafari R. SARS-CoV-2 and Guillain-Barré Syndrome: Lessons from Viral Infections. Viral Immunol 2022; 35:404-417. [PMID: 35766944 DOI: 10.1089/vim.2021.0187] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) is responsible for the COVID-19 pandemic. COVID-19 has a broad clinical spectrum from asymptomatic patients to multiorgan dysfunction and septic shock. Most of the common symptoms of COVID-19 are classified as respiratory disorders, but some reports show neurological involvements. During the COVID-19 pandemic, a case series of neurological complications, such as Guillain-Barré syndrome (GBS), were reported. GBS is a neuroimmune disorder with acute inflammatory radicular polyneuropathy in different parts of the peripheral nerve. Some studies have reported GBS as an inflammatory neuropathy related to various viral infections, such as cytomegalovirus (CMV), Epstein-Barr Virus (EBV), herpes simplex virus (HSV), human immunodeficiency virus (HIV), influenza, and Zika virus. There are some immunomodulation approaches for the management of GBS. Studies have evaluated the effects of the various therapeutic approaches, including intravenous immunoglobulin (IVIG), plasma exchange (PE), complement inhibitors, and corticosteroids to regulate overactivation of immune responses during GBS in experimental and clinical studies. In this regard, the possible association between GBS and SARS-CoV-2 infection during the outbreak of the current pandemic and also the mentioned therapeutic approaches were reviewed.
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Affiliation(s)
- Sepideh Meidaninikjeh
- Department of Microbiology, Faculty of Biological Sciences, Alzahra University, Tehran, Iran.,Cancer Biomedical Center (CBC) Research Institute, Tehran, Iran
| | - Nasim Sabouni
- Department of Immunology, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Mahdie Taheri
- Department of Microbiology, School of Medicine, Golestan University of Medical Sciences, Gorgan, Iran
| | - Mahdis Borjkhani
- Bioprocess Engineering Department, National Institute of Genetic Engineering and Biotechnology (NIGEB), Tehran, Iran
| | - Sajad Bengar
- Department of Microbiology, Faculty of Science, Shahre Ghods Branch, Islamic Azad University, Shahre Ghods, Tehran, Iran
| | - Naime Majidi Zolbanin
- Experimental and Applied Pharmaceutical Research Center, Urmia University of Medical Sciences, Urmia, Iran.,Department of Pharmacology and Toxicology, Faculty of Pharmacy, Urmia University of Medical Sciences, Urmia, Iran
| | - Ahmad Khalili
- Cancer Biomedical Center (CBC) Research Institute, Tehran, Iran
| | - Reza Jafari
- Cellular and Molecular Research Center, Cellular and Molecular Medicine Institute, Urmia University of Medical Sciences, Urmia, Iran
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12
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Current and Emerging Pharmacotherapeutic Interventions for the Treatment of Peripheral Nerve Disorders. Pharmaceuticals (Basel) 2022; 15:ph15050607. [PMID: 35631433 PMCID: PMC9144529 DOI: 10.3390/ph15050607] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Revised: 04/26/2022] [Accepted: 05/11/2022] [Indexed: 11/16/2022] Open
Abstract
Peripheral nerve disorders are caused by a range of different aetiologies. The range of causes include metabolic conditions such as diabetes, obesity and chronic kidney disease. Diabetic neuropathy may be associated with severe weakness and the loss of sensation, leading to gangrene and amputation in advanced cases. Recent studies have indicated a high prevalence of neuropathy in patients with chronic kidney disease, also known as uraemic neuropathy. Immune-mediated neuropathies including Guillain-Barré syndrome and chronic inflammatory demyelinating polyradiculoneuropathy may cause significant physical disability. As survival rates continue to improve in cancer, the prevalence of treatment complications, such as chemotherapy-induced peripheral neuropathy, has also increased in treated patients and survivors. Notably, peripheral neuropathy associated with these conditions may be chronic and long-lasting, drastically affecting the quality of life of affected individuals, and leading to a large socioeconomic burden. This review article explores some of the major emerging clinical and experimental therapeutic agents that have been investigated for the treatment of peripheral neuropathy due to metabolic, toxic and immune aetiologies.
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13
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McCombe JA, Pittock SJ. Anti-complement Agents for Autoimmune Neurological Disease. Neurotherapeutics 2022; 19:711-728. [PMID: 35553024 PMCID: PMC9294087 DOI: 10.1007/s13311-022-01223-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/14/2022] [Indexed: 01/06/2023] Open
Abstract
In recent years, there has been increasing recognition of the diversity of autoimmune neurological diseases affecting all levels of the nervous system. A growing understanding of disease pathogenesis has enabled us to better target specific elements of the immune system responsible for the cell dysfunction and cell destruction seen in these diseases. This is no better demonstrated than in the development of complement directed therapies for the treatment of complement mediated autoimmune neurological conditions. Herein, we describe the basic elements of the complement cascade, provide an overview of select autoimmune neurological diseases whose pathogenesis is mediated by complement, the effector system of autoantigen bound autoantibodies, and discuss the complement directed therapies trialed in the treatment of these diseases. Several complement-directed therapies have demonstrated benefit in the treatment of autoimmune neurological diseases; we also review the trials resulting in the approval of these therapies for the treatment of AChR Ab-positive myasthenia gravis (MG) and neuromyelitis spectrum disorder. Finally, on the heels of the recent successes described, we discuss possibilities for the future, including additional targeted therapies with greater ease of administration, improved risk profiles, and other possible uses for therapeutics targeting elements of the complement cascade.
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Affiliation(s)
- Jennifer A McCombe
- Department of Neurology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
- Division of Neurology, Department of Medicine, University of Alberta, Edmonton, AB, Canada
| | - Sean J Pittock
- Department of Neurology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
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14
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Querol LA, Hartung HP, Lewis RA, van Doorn PA, Hammond TR, Atassi N, Alonso-Alonso M, Dalakas MC. The Role of the Complement System in Chronic Inflammatory Demyelinating Polyneuropathy: Implications for Complement-Targeted Therapies. Neurotherapeutics 2022; 19:864-873. [PMID: 35378684 PMCID: PMC9294101 DOI: 10.1007/s13311-022-01221-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/12/2022] [Indexed: 01/01/2023] Open
Abstract
Chronic inflammatory demyelinating polyneuropathy (CIDP) is the most common, heterogeneous, immune-mediated neuropathy, characterized by predominant demyelination of motor and sensory nerves. CIDP follows a relapsing-remitting or a progressive course and causes substantial disability. The pathogenesis of CIDP involves a complex interplay of multiple aberrant immune responses, creating a pro-inflammatory environment, subsequently inflicting damage on the myelin sheath. Though the exact triggers are unclear, diverse immune mechanisms encompassing cellular and humoral pathways are implicated. The complement system appears to play a role in promoting macrophage-mediated demyelination. Complement deposition in sural nerve biopsies, as well as signs of increased complement activation in serum and CSF of patients with CIDP, suggest complement involvement in CIDP pathogenesis. Here, we present a comprehensive overview of the preclinical and clinical evidence supporting the potential role of the complement system in CIDP. This understanding furnishes a strong rationale for targeting the complement system to develop new therapies that could serve the unmet needs of patients affected by CIDP, particularly in those refractory to standard therapies.
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Affiliation(s)
- Luis A Querol
- Neuromuscular Diseases Unit, Department of Neurology, Hospital de La Santa Creu I Sant Pau, Barcelona, Spain
| | - Hans-Peter Hartung
- Department of Neurology, Heinrich Heine University, Düsseldorf, Germany
- Brain and Mind Center, University of Sydney, Sydney, Australia
- Department of Neurology, Medical University of Vienna, Vienna, Austria
- Department of Neurology, Palacky University Olomouc, Olomouc, Czech Republic
| | | | | | | | - Nazem Atassi
- Sanofi, Neurology Clinical Development, Cambridge, MA, USA
| | | | - Marinos C Dalakas
- Department of Neurology, Thomas Jefferson University Hospital, Philadelphia, PA, USA.
- Neuroimmunology National and Kapodistrian University of Athens Medical School, Athens, Greece.
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15
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Rajabally YA. Immunoglobulin and Monoclonal Antibody Therapies in Guillain-Barré Syndrome. Neurotherapeutics 2022; 19:885-896. [PMID: 35648286 PMCID: PMC9159039 DOI: 10.1007/s13311-022-01253-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/20/2022] [Indexed: 12/29/2022] Open
Abstract
Guillain-Barré syndrome (GBS) is an acute autoimmune polyradiculoneuropathy affecting 1-2 subjects per 100,000 every year worldwide. It causes, in its classic form, symmetric weakness in the proximal and distal limb muscles with common involvement of the cranial nerves, particularly facial weakness. Respiratory function is compromised in a case in four. Randomised controlled trials have demonstrated the benefit of therapeutic plasma exchange in hastening time to recovery. Intravenous immunoglobulin was subsequently shown to be as efficacious as plasma exchange in adult subjects. In children, few trials have shown the benefit of intravenous immunoglobulin versus supportive care. Pharmacokinetic studies suggested a relationship between increase in immunoglobulin G level post-infusion and outcome, implying administration of larger doses may be beneficial in subjects with poor prognosis. However, a subsequent trial of a second dose of immunoglobulin in such subjects failed to show improved outcome, while demonstrating a higher risk of thromboembolic side-effects. Monoclonal antibody therapy has more recently been investigated for GBS, after multiple studies in animal models, with different agents and variable postulated mechanisms of action. Eculizumab, a humanised monoclonal antibody against the complement protein C5, was tested in in two randomised, double-blind, placebo-controlled phase 2 trials. Neither showed benefit versus immunoglobulins alone on disability level at 4 weeks, although one study importantly suggested possible, clinically highly relevant, late effects on normalising function. A phase 3 trial is in progress. Preliminary results of a placebo-controlled ongoing study of ANX005, a humanised recombinant antibody against C1q inhibiting the complement cascade, have been promising.
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Affiliation(s)
- Yusuf A Rajabally
- Aston Medical School, Aston University, Birmingham, B4 7ET, UK.
- Inflammatory Neuropathy Clinic, University Hospitals Birmingham, Queen Elizabeth Hospital, Birmingham, B15 2TH, UK.
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16
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Halstead SK, Gourlay DS, Penderis J, Bianchi E, Dondi M, Wessmann A, Musteata M, Le Chevoir M, Martinez-Anton L, Bhatti SFM, Volk H, Mateo I, Tipold A, Ives E, Pakozdy A, Gutierrez-Quintana R, Brocal J, Whitehead Z, Granger N, Pazzi P, Harcourt-Brown T, José-López R, Rupp S, Schenk HC, Smith P, Gandini G, Menchetti M, Mortera-Balsa V, Rusbridge C, Tauro A, Cozzi F, Deutschland M, Tirrito F, Freeman P, Lowrie M, Jackson MR, Willison HJ, Rupp A. Serum anti-GM2 and anti-GalNAc-GD1a IgG antibodies are biomarkers for acute canine polyradiculoneuritis. J Small Anim Pract 2022; 63:104-112. [PMID: 34791652 DOI: 10.1111/jsap.13439] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Revised: 08/13/2021] [Accepted: 09/19/2021] [Indexed: 11/29/2022]
Abstract
OBJECTIVES A previous single-country pilot study indicated serum anti-GM2 and anti-GA1 anti-glycolipid antibodies as potential biomarkers for acute canine polyradiculoneuritis. This study aims to validate these findings in a large geographically heterogenous cohort. MATERIALS AND METHODS Sera from 175 dogs clinically diagnosed with acute canine polyradiculoneuritis, 112 dogs with other peripheral nerve, cranial nerve or neuromuscular disorders and 226 neurologically normal dogs were screened for anti-glycolipid antibodies against 11 common glycolipid targets to determine the immunoglobulin G anti-glycolipid antibodies with the highest combined sensitivity and specificity for acute canine polyradiculoneuritis. RESULTS Anti-GM2 anti-glycolipid antibodies reached the highest combined sensitivity and specificity (sensitivity: 65.1%, 95% confidence interval 57.6 to 72.2%; specificity: 90.2%, 95% confidence interval 83.1 to 95.0%), followed by anti-GalNAc-GD1a anti-glycolipid antibodies (sensitivity: 61.7%, 95% confidence interval 54.1 to 68.9%; specificity: 89.3%, 95% confidence interval 82.0 to 94.3%) and these anti-glycolipid antibodies were frequently present concomitantly. Anti-GA1 anti-glycolipid antibodies were detected in both acute canine polyradiculoneuritis and control animals. Both for anti-GM2 and anti-GalNAc-GD1a anti-glycolipid antibodies, sex was found a significantly associated factor with a female to male odds ratio of 2.55 (1.27 to 5.31) and 3.00 (1.22 to 7.89), respectively. Anti-GalNAc-GD1a anti-glycolipid antibodies were more commonly observed in dogs unable to walk (OR 4.56, 1.56 to 14.87). CLINICAL SIGNIFICANCE Anti-GM2 and anti-GalNAc-GD1a immunoglobulin G anti-glycolipid antibodies represent serum biomarkers for acute canine polyradiculoneuritis.
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Affiliation(s)
- S K Halstead
- Neuroimmunology Laboratory, Institute of Infection, Immunity and Inflammation, University of Glasgow, Glasgow, G12 8TA, UK
| | - D S Gourlay
- Neuroimmunology Laboratory, Institute of Infection, Immunity and Inflammation, University of Glasgow, Glasgow, G12 8TA, UK
| | - J Penderis
- Vet Extra Neurology, Broadleys Veterinary Hospital, Stirling, FK7 7LE, UK
| | - E Bianchi
- Department of Veterinary Science, University of Parma, 43126, Parma, Italy
| | - M Dondi
- Department of Veterinary Science, University of Parma, 43126, Parma, Italy
| | - A Wessmann
- Neurology and Neurosurgery Service, Pride Veterinary Centre, Pride Park, Derby, DE24 8HX, UK
| | - M Musteata
- Neurology Service, Faculty of Veterinary Medicine, University of Agricultural Sciences and Veterinary Medicine, Iași, 700489, Romania
| | - M Le Chevoir
- Department of Neurology and Neurosurgery, University of Melbourne, Werribee, Victoria, 3030, Australia
| | - L Martinez-Anton
- Chestergates Veterinary Specialists, Telford Court, Chestergates, CH1 6LT, UK
| | - S F M Bhatti
- Small Animal Department, Small Animal Teaching Hospital, Faculty of Veterinary Medicine, Ghent University, 9820, Merelbeke, Belgium
| | - H Volk
- Department of Small Animal Medicine and Surgery, University of Veterinary Medicine Hannover, 30559, Hannover, Germany
| | - I Mateo
- Servicio de Neurología, Hospital Clínico Veterinario - Universidad Alfonso X el Sabio, Madrid, Spain
| | - A Tipold
- Department of Small Animal Medicine and Surgery, University of Veterinary Medicine Hannover, 30559, Hannover, Germany
| | - E Ives
- Anderson Moores Veterinary Specialists, Hursley, Winchester, SO21 2LL, UK
| | - A Pakozdy
- University Hospital for Small Animals, University of Veterinary Medicine, Vienna, Austria
| | | | - J Brocal
- Wear Referrals Veterinary Hospital, Bradbury, Stockton-on-Tees, TS21 2ES, UK
| | - Z Whitehead
- Department of Companion Animal Clinical Studies, Faculty of Veterinary Science, University of Pretoria, Onderstepoort, 0110, South Africa
| | - N Granger
- The Royal Veterinary College, University of London, Hatfield, Hertfordshire, UK.,CVS Referrals, Bristol Veterinary Specialists at Highcroft, Bristol, UK
| | - P Pazzi
- Department of Companion Animal Clinical Studies, Faculty of Veterinary Science, University of Pretoria, Onderstepoort, 0110, South Africa
| | - T Harcourt-Brown
- Langford Veterinary Services, School of Veterinary Sciences, University of Bristol, Lower Langford, BS40 5DU, UK
| | - R José-López
- School of Veterinary Medicine, University of Glasgow, Glasgow, G61 1QH, UK
| | - S Rupp
- Tierklinik Hofheim, 65719, Hofheim, Germany
| | - H C Schenk
- Tierklinik Lüneburg, 21337, Lüneburg, Germany
| | - P Smith
- Hamilton Specialist Referrals, Cressex Business Park, High Wycombe, HP12 3SD, UK
| | - G Gandini
- Department of Veterinary Medical Sciences, University of Bologna, 40064, Ozzano dell'Emilia, Italy
| | - M Menchetti
- Neurology and Neurosurgery Division, San Marco Veterinary Clinic, Veggiano, Italy
| | - V Mortera-Balsa
- North Downs Specialist Referrals, 3&4 The Brewerstreet Dairy Business Park, Bletchingley, Surrey, RH1 4QP, UK
| | - C Rusbridge
- Neurology Section, Fitzpatrick Referrals, Godalming, Surrey, GU2 7AL, UK.,School of Veterinary Medicine, Faculty of Health & Medical Sciences, University of Surrey, Guildford, Surrey, GU2 7AL, UK
| | - A Tauro
- Chestergates Veterinary Specialists, Telford Court, Chestergates, CH1 6LT, UK
| | - F Cozzi
- Clinica Neurologica Veterinaria, 20148, Milan, Italy
| | | | - F Tirrito
- Clinica Neurologica Veterinaria, 20148, Milan, Italy
| | - P Freeman
- The Queen's Veterinary School Hospital, Cambridge, CB3 0ES, UK
| | - M Lowrie
- Dovecote Veterinary Hospital, Castle Donington, Derby, DE74 2LJ, UK
| | - M R Jackson
- Institute of Cancer Sciences, University of Glasgow, Bearsden, G61 1QH, UK
| | - H J Willison
- Neuroimmunology Laboratory, Institute of Infection, Immunity and Inflammation, University of Glasgow, Glasgow, G12 8TA, UK
| | - A Rupp
- School of Veterinary Medicine, University of Glasgow, Glasgow, G61 1QH, UK
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17
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[Pathophysiological and diagnostic aspects of Guillain-Barré syndrome]. Rev Med Interne 2022; 43:419-428. [PMID: 34998626 DOI: 10.1016/j.revmed.2021.12.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Accepted: 12/23/2021] [Indexed: 11/22/2022]
Abstract
Guillain-Barré syndrome (GBS) is the most common cause of acute neuropathy. It usually onset with a rapidly progressive ascending bilateral weakness with sensory disturbances, and patients may require intensive treatment and close monitoring as about 30% have a respiratory muscle weakness and about 10% have autonomic dysfunction. The diagnosis of GBS is based on clinical history and examination. Complementary examinations are performed to rule out a differential diagnosis and to secondarily confirm the diagnosis. GBS is usually preceded by an infectious event in ≈ 2/3 of cases. Infection leads to an immune response directed against carbohydrate antigens located on the infectious agent and the formation of anti-ganglioside antibodies. By molecular mimicry, these antibodies can target structurally similar carbohydrates found on host's nerves. Their binding results in nerve conduction failure or/and demyelination which can lead to axonal loss. Some anti-ganglioside antibodies are associated with particular variants of GBS: the Miller-Fisher syndrome, facial diplegia and paresthesias, the pharyngo-cervico-brachial variant, the paraparetic variant, and the Bickerstaff brainstem encephalitis. Their semiological differences might be explained by a distinct expression of gangliosides among nerves. The aim of this review is to present pathophysiological aspects and the diagnostic approach of GBS and its variants.
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18
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Berkowitz S, Chapman J, Dori A, Gofrit SG, Maggio N, Shavit-Stein E. Complement and Coagulation System Crosstalk in Synaptic and Neural Conduction in the Central and Peripheral Nervous Systems. Biomedicines 2021; 9:biomedicines9121950. [PMID: 34944766 PMCID: PMC8698364 DOI: 10.3390/biomedicines9121950] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2021] [Revised: 12/16/2021] [Accepted: 12/17/2021] [Indexed: 12/12/2022] Open
Abstract
Complement and coagulation are both key systems that defend the body from harm. They share multiple features and are similarly activated. They each play individual roles in the systemic circulation in physiology and pathophysiology, with significant crosstalk between them. Components from both systems are mapped to important structures in the central nervous system (CNS) and peripheral nervous system (PNS). Complement and coagulation participate in critical functions in neuronal development and synaptic plasticity. During pathophysiological states, complement and coagulation factors are upregulated and can modulate synaptic transmission and neuronal conduction. This review summarizes the current evidence regarding the roles of the complement system and the coagulation cascade in the CNS and PNS. Possible crosstalk between the two systems regarding neuroinflammatory-related effects on synaptic transmission and neuronal conduction is explored. Novel treatment based on the modulation of crosstalk between complement and coagulation may perhaps help to alleviate neuroinflammatory effects in diseased states of the CNS and PNS.
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Affiliation(s)
- Shani Berkowitz
- Department of Neurology, The Chaim Sheba Medical Center, Ramat Gan 5266202, Israel; (S.B.); (J.C.); (A.D.); (S.G.G.); (N.M.)
- Department of Neurology and Neurosurgery, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
| | - Joab Chapman
- Department of Neurology, The Chaim Sheba Medical Center, Ramat Gan 5266202, Israel; (S.B.); (J.C.); (A.D.); (S.G.G.); (N.M.)
- Department of Neurology and Neurosurgery, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
- Department of Physiology and Pharmacology, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
- Robert and Martha Harden Chair in Mental and Neurological Diseases, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
| | - Amir Dori
- Department of Neurology, The Chaim Sheba Medical Center, Ramat Gan 5266202, Israel; (S.B.); (J.C.); (A.D.); (S.G.G.); (N.M.)
- Department of Neurology and Neurosurgery, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
- Talpiot Medical Leadership Program, The Chaim Sheba Medical Center, Ramat Gan 6997801, Israel
| | - Shany Guly Gofrit
- Department of Neurology, The Chaim Sheba Medical Center, Ramat Gan 5266202, Israel; (S.B.); (J.C.); (A.D.); (S.G.G.); (N.M.)
| | - Nicola Maggio
- Department of Neurology, The Chaim Sheba Medical Center, Ramat Gan 5266202, Israel; (S.B.); (J.C.); (A.D.); (S.G.G.); (N.M.)
- Department of Neurology and Neurosurgery, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
- Talpiot Medical Leadership Program, The Chaim Sheba Medical Center, Ramat Gan 6997801, Israel
- Sagol School of Neuroscience, Tel Aviv University, Tel Aviv 6997801, Israel
| | - Efrat Shavit-Stein
- Department of Neurology, The Chaim Sheba Medical Center, Ramat Gan 5266202, Israel; (S.B.); (J.C.); (A.D.); (S.G.G.); (N.M.)
- Department of Neurology and Neurosurgery, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
- Correspondence: ; Tel.: +972-50-921-0400
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19
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Anti-MAG neuropathy: From biology to clinical management. J Neuroimmunol 2021; 361:577725. [PMID: 34610502 DOI: 10.1016/j.jneuroim.2021.577725] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Accepted: 09/20/2021] [Indexed: 12/19/2022]
Abstract
The acquired chronic demyelinating neuropathies include a growing number of disease entities that have characteristic, often overlapping, clinical presentations, mediated by distinct immune mechanisms, and responding to different therapies. After the discovery in the early 1980s, that the myelin associated glycoprotein (MAG) is a target antigen in an autoimmune demyelinating neuropathy, assays to measure the presence of anti-MAG antibodies were used as the basis to diagnose the anti-MAG neuropathy. The route was open for describing the clinical characteristics of this new entity as a chronic distal large fiber sensorimotor neuropathy, for studying its pathogenesis and devising specific treatment strategies. The initial use of chemotherapeutic agents was replaced by the introduction in the late 1990s of rituximab, a monoclonal antibody against CD20+ B-cells. Since then, other anti-B cells agents have been introduced. Recently a novel antigen-specific immunotherapy neutralizing the anti-MAG antibodies with a carbohydrate-based ligand mimicking the natural HNK-1 glycoepitope has been described.
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20
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Latov N. Immune mechanisms, the role of complement, and related therapies in autoimmune neuropathies. Expert Rev Clin Immunol 2021; 17:1269-1281. [PMID: 34751638 DOI: 10.1080/1744666x.2021.2002147] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
INTRODUCTION Autoimmune neuropathies have diverse presentations and underlying immune mechanisms. Demonstration of efficacy of therapeutic agents that inhibit the complement cascade would confirm the role of complement activation. AREAS COVERED A review of the pathophysiology of the autoimmune neuropathies, to identify those that are likely to be complement mediated. EXPERT OPINION Complement mediated mechanisms are implicated in the acute and chronic neuropathies associated with IgG or IgM antibodies that target the Myelin Associated Glycoprotein (MAG) or gangliosides in the peripheral nerves. Antibody and complement mechanisms are also suspected in the Guillain-Barré syndrome and chronic inflammatory demyelinating neuropathy, given the therapeutic response to plasmapheresis or intravenous immunoglobulins, even in the absence of an identifiable target antigen. Complement is unlikely to play a role in paraneoplastic sensory neuropathy associated with antibodies to HU/ANNA-1 given its intracellular localization. In chronic demyelinating neuropathy with anti-nodal/paranodal CNTN1, NFS-155, and CASPR1 antibodies, myotonia with anti-VGKC LGI1 or CASPR2 antibodies, or autoimmune autonomic neuropathy with anti-gAChR antibodies, the response to complement inhibitory agents would depend on the extent to which the antibodies exert their effects through complement dependent or independent mechanisms. Complement is also likely to play a role in Sjogren's, vasculitic, and cryoglobulinemic neuropathies.
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Affiliation(s)
- Norman Latov
- Department of Neurology, Weill Cornell Medical College, New York, USA
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Florian IA, Lupan I, Sur L, Samasca G, Timiș TL. To be, or not to be… Guillain-Barré Syndrome. Autoimmun Rev 2021; 20:102983. [PMID: 34718164 DOI: 10.1016/j.autrev.2021.102983] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Accepted: 08/02/2021] [Indexed: 02/06/2023]
Abstract
Guillain-Barré Syndrome (GBS) is currently the most frequent cause of acute flaccid paralysis on a global scale, being an autoimmune disorder wherein demyelination of the peripheral nerves occurs. Its main clinical features are a symmetrical ascending muscle weakness with reduced osteotendinous reflexes and variable sensory involvement. GBS most commonly occurs after an infection, especially viral (including COVID-19), but may also transpire after immunization with certain vaccines or in the development of specific malignancies. Immunoglobulins, plasmapheresis, and glucocorticoids represent the principal treatment modalities, however patients with severe disease progression may require supportive therapy in an intensive care unit. Due to its symptomology, which overlaps with numerous neurological and infectious illnesses, the diagnosis of GBS may often be misattributed to pathologies that are essentially different from this syndrome. Moreover, many of these require specific treatment methods distinct to those recommended for GBS, in lack of which the prognosis of the patient is drastically affected. Such diseases include exposure to toxins either environmental or foodborne, central nervous system infections, metabolic or serum ion alterations, demyelinating pathologies, or even conditions amenable to neurosurgical intervention. This extensive narrative review aims to systematically and comprehensively tackle the most notable and challenging differential diagnoses of GBS, emphasizing on the clinical discrepancies between the diseases, the appropriate paraclinical investigations, and suitable management indications.
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Affiliation(s)
- Ioan Alexandru Florian
- Department of Neurology, Cluj County Emergency Clinical Hospital, Cluj-Napoca, Romania, Department of Neurosurgery, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania.
| | - Iulia Lupan
- Department of Molecular Biology, Babes Bolyai University, Cluj-Napoca, Romania.
| | - Lucia Sur
- Department of Pediatrics I, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania.
| | - Gabriel Samasca
- Department of Immunology, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania.
| | - Teodora Larisa Timiș
- Department of Physiology, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania.
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Lin J, Gao Q, Xiao K, Tian D, Hu W, Han Z. Efficacy of therapies in the treatment of Guillain-Barre syndrome: A network meta-analysis. Medicine (Baltimore) 2021; 100:e27351. [PMID: 34731107 PMCID: PMC8519256 DOI: 10.1097/md.0000000000027351] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Accepted: 09/09/2021] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Guillain-Barre syndrome (GBS) is a disease with the features of acuteness, paralysis, inflammation, and in peripheral nerves. There are many current treatment options with varying efficacy, and to assess their effectiveness, we performed a network meta-analysis (NMA). The study protocol was registered at PROSPERO (CRD: 42019119178). Posted history: this manuscript was previously posted to medRxiv: doi: https://doi.org/10.1101/2020.06.03.20121780. METHODS The literature search database includes Web of Science, PubMed, Embase, and the Cochrane library that meets the requirements. We performed the NMA using controlled trials with 2 kinds of outcomes. We used the gemtc R package to perform the NMA to evaluate different GBS treatments' relative results. The consistency of direct and indirect evidence was also assessed by R software with gemtc package. RESULTS This NMA study included a total of 2474 subjects from 28 trials with 15 kinds of therapies. No improvement was observed in methylprednisolone and prednisolone compared with placebo. Conversely, plasma exchange (PE) and intravenous immunoglobulin (IVIg) were more effective than placebo. There was no significant difference between different doses and courses of PE and IVIg. For combination treatment, such as IVIg+eculizumab, immunoadsorption followed by IVIg and PE followed by IVIg, they didn't show significant advantages than IVIg and PE in NMA. On the consistency examination between direct and indirect evidence, there was no apparent heterogeneity between them. Funnel plots indicated there was little possibility of publication bias in this study. CONCLUSION PE or IVIg has significant efficacy for GBS patients. The effects of several kinds of therapies should be further explored. Corticosteroids have no considerable impact on GBS.
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Affiliation(s)
- Jingfeng Lin
- Hangzhou Seventh People's Hospital, Hangzhou, China
| | - Qiang Gao
- Beijing University of Chinese Medicine, Beijing, China
| | - Kang Xiao
- Beijing University of Chinese Medicine, Beijing, China
| | - Danfeng Tian
- Beijing University of Chinese Medicine, Beijing, China
| | - Wenyue Hu
- Beijing University of Chinese Medicine, Beijing, China
| | - Zhenyun Han
- Shenzhen Hospital of Beijing University of Chinese Medicine (Longgang), Shenzhen, China
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Querol L, Lleixà C. Novel Immunological and Therapeutic Insights in Guillain-Barré Syndrome and CIDP. Neurotherapeutics 2021; 18:2222-2235. [PMID: 34549385 PMCID: PMC8455117 DOI: 10.1007/s13311-021-01117-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/02/2021] [Indexed: 12/22/2022] Open
Abstract
Inflammatory neuropathies are a heterogeneous group of rare diseases of the peripheral nervous system that include acute and chronic diseases, such as Guillain-Barré syndrome (GBS) and chronic inflammatory demyelinating polyradiculoneuropathy (CIDP). The etiology and pathophysiological mechanisms of inflammatory neuropathies are only partly known, but are considered autoimmune disorders in which an aberrant immune response, including cellular and humoral components, is directed towards components of the peripheral nerve causing demyelination and axonal damage. Therapy of these disorders includes broad-spectrum immunomodulatory and immunosuppressive treatments, such as intravenous immunoglobulin, corticosteroids, or plasma exchange. However, a significant proportion of patients do not respond to any of these therapies, and treatment selection is not optimized according to disease pathophysiology. Therefore, research on disease pathophysiology aiming to reveal clinically and functionally relevant disease mechanisms and the development of new treatment approaches are needed to optimize disease outcomes in CIDP and GBS. This topical review describes immunological progress that may help guide therapeutic strategies in the future in these two disorders.
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Affiliation(s)
- Luis Querol
- Neuromuscular Diseases Unit, Department of Neurology, Hospital de La Santa Creu I Sant Pau, Universitat Autònoma de Barcelona, Mas Casanovas 90, 08041, Barcelona, Spain.
- Centro Para La Investigación Biomédica en Red en Enfermedades Raras (CIBERER), Madrid, Spain.
| | - Cinta Lleixà
- Neuromuscular Diseases Unit, Department of Neurology, Hospital de La Santa Creu I Sant Pau, Universitat Autònoma de Barcelona, Mas Casanovas 90, 08041, Barcelona, Spain
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Hagen KM, Ousman SS. The Neuroimmunology of Guillain-Barré Syndrome and the Potential Role of an Aging Immune System. Front Aging Neurosci 2021; 12:613628. [PMID: 33584245 PMCID: PMC7873882 DOI: 10.3389/fnagi.2020.613628] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Accepted: 12/11/2020] [Indexed: 12/15/2022] Open
Abstract
Guillain-Barré syndrome (GBS) is a paralyzing autoimmune condition affecting the peripheral nervous system (PNS). Within GBS there are several variants affecting different aspects of the peripheral nerve. In general, there appears to be a role for T cells, macrophages, B cells, and complement in initiating and perpetuating attacks on gangliosides of Schwann cells and axons. Of note, GBS has an increased prevalence and severity with increasing age. In addition, there are alterations in immune cell functioning that may play a role in differences in GBS with age alongside general age-related declines in reparative processes (e.g., delayed de-differentiation of Schwann cells and decline in phagocytic ability of macrophages). The present review will explore the immune response in GBS as well as in animal models of several variants of the disorder. In addition, the potential involvement of an aging immune system in contributing to the increased prevalence and severity of GBS with age will be theorized.
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Affiliation(s)
- Kathleen M. Hagen
- Department of Neuroscience, Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
| | - Shalina S. Ousman
- Departments of Clinical Neurosciences and Cell Biology and Anatomy, Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
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25
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Barnes SL, Herkes GK. Guillain–Barré syndrome: clinical features, treatment choices and outcomes in an Australian cohort. Intern Med J 2020; 50:1500-1504. [DOI: 10.1111/imj.14705] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2019] [Revised: 11/08/2019] [Accepted: 11/09/2019] [Indexed: 12/20/2022]
Affiliation(s)
- Stephanie L. Barnes
- Department of Neurology Concord Repatriation General Hospital Sydney New South Wales Australia
- Faculty of Medicine University of Notre Dame Sydney New South Wales Australia
- Department of Neurology Royal North Shore Hospital Sydney New South Wales Australia
| | - Geoffrey K. Herkes
- Department of Neurology Royal North Shore Hospital Sydney New South Wales Australia
- Faculty of Medicine University of Sydney Sydney New South Wales Australia
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26
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Gavriilaki M, Kimiskidis VK, Gavriilaki E. Precision Medicine in Neurology: The Inspirational Paradigm of Complement Therapeutics. Pharmaceuticals (Basel) 2020; 13:E341. [PMID: 33114553 PMCID: PMC7693884 DOI: 10.3390/ph13110341] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2020] [Revised: 10/19/2020] [Accepted: 10/22/2020] [Indexed: 12/12/2022] Open
Abstract
Precision medicine has emerged as a central element of healthcare science. Complement, a component of innate immunity known for centuries, has been implicated in the pathophysiology of numerous incurable neurological diseases, emerging as a potential therapeutic target and predictive biomarker. In parallel, the innovative application of the first complement inhibitor in clinical practice as an approved treatment of myasthenia gravis (MG) and neuromyelitis optica spectrum disorders (NMOSD) related with specific antibodies raised hope for the implementation of personalized therapies in detrimental neurological diseases. A thorough literature search was conducted through May 2020 at MEDLINE, EMBASE, Cochrane Library and ClinicalTrials.gov databases based on medical terms (MeSH)" complement system proteins" and "neurologic disease". Complement's role in pathophysiology, monitoring of disease activity and therapy has been investigated in MG, multiple sclerosis, NMOSD, spinal muscular atrophy, amyotrophic lateral sclerosis, Parkinson, Alzheimer, Huntington disease, Guillain-Barré syndrome, chronic inflammatory demyelinating polyneuropathy, stroke, and epilepsy. Given the complexity of complement diagnostics and therapeutics, this state-of-the-art review aims to provide a brief description of the complement system for the neurologist, an overview of novel complement inhibitors and updates of complement studies in a wide range of neurological disorders.
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Affiliation(s)
- Maria Gavriilaki
- Postgraduate Course, School of Medicine, Aristotle University of Thessaloniki, 54124 Thessaloniki, Greece;
| | - Vasilios K. Kimiskidis
- Postgraduate Course, School of Medicine, Aristotle University of Thessaloniki, 54124 Thessaloniki, Greece;
- Laboratory of Clinical Neurophysiology, AHEPA Hospital, Aristotle University of Thessaloniki, 54621 Thessaloniki, Greece
| | - Eleni Gavriilaki
- Hematology Department-BMT Unit, G. Papanicolaou Hospital, 57010 Thessaloniki, Greece;
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Dalakas MC, Alexopoulos H, Spaeth PJ. Complement in neurological disorders and emerging complement-targeted therapeutics. Nat Rev Neurol 2020; 16:601-617. [PMID: 33005040 PMCID: PMC7528717 DOI: 10.1038/s41582-020-0400-0] [Citation(s) in RCA: 134] [Impact Index Per Article: 33.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/07/2020] [Indexed: 12/30/2022]
Abstract
The complement system consists of a network of plasma and membrane proteins that modulate tissue homeostasis and contribute to immune surveillance by interacting with the innate and adaptive immune systems. Dysregulation, impairment or inadvertent activation of complement components contribute to the pathogenesis of some autoimmune neurological disorders and could even contribute to neurodegenerative diseases. In this Review, we summarize current knowledge about the main functions of the complement pathways and the involvement of complement in neurological disorders. We describe the complex network of complement proteins that target muscle, the neuromuscular junction, peripheral nerves, the spinal cord or the brain and discuss the autoimmune mechanisms of complement-mediated myopathies, myasthenia, peripheral neuropathies, neuromyelitis and other CNS disorders. We also consider the emerging role of complement in some neurodegenerative diseases, such as Alzheimer disease, amyotrophic lateral sclerosis and even schizophrenia. Finally, we provide an overview of the latest complement-targeted immunotherapies including monoclonal antibodies, fusion proteins and peptidomimetics that have been approved, that are undergoing phase I–III clinical trials or that show promise for the treatment of neurological conditions that respond poorly to existing immunotherapies. In this Review, Dalakas et al. discuss the complement system, the role it plays in autoimmune neurological disease and neurodegenerative disease, and provide an overview of the latest therapeutics that target complement and that can be used for or have potential in neurological disorders. Complement has an important physiological role in host immune defences and tissue remodelling. The physiological role of complement extends to the regulation of synaptic development. Complement has a key pathophysiological role in autoimmune neurological diseases and mediates the actions of pathogenic autoantibodies, such as acetylcholine receptor antibodies and aquaporin 4 antibodies. For some autoimmune neurological diseases, such as myasthenia gravis and neuromyelitis optica spectrum disorders, approved complement-targeted treatments are now available. Complement also seems to be of pathogenic relevance in neurodegenerative diseases such as Alzheimer disease, in which innate immune-driven inflammation is receiving increasing attention. The field of complement-targeted therapeutics is rapidly expanding, with several FDA-approved agents and others currently in phase II and phase III clinical trials.
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Affiliation(s)
- Marinos C Dalakas
- Department of Neurology, Thomas Jefferson University, Philadelphia, PA, USA. .,Neuroimmunology Unit, Department of Pathophysiology, Faculty of Medicine, National and Kapodistrian University of Athens, Athens, Greece.
| | - Harry Alexopoulos
- Neuroimmunology Unit, Department of Pathophysiology, Faculty of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Peter J Spaeth
- Institute of Pharmacology, University of Bern, Bern, Switzerland
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Roy B, Nowak RJ. Eculizumab in Acute Motor Axonal Neuropathy: An Ethical Application of an Off-Label Indication. J Clin Neuromuscul Dis 2020; 22:63-64. [PMID: 32833730 DOI: 10.1097/cnd.0000000000000295] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Bhaskar Roy
- Department of Neurology, Yale School of Medicine, New Haven, CT
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Pharmacology, Pharmacokinetics and Pharmacodynamics of Eculizumab, and Possibilities for an Individualized Approach to Eculizumab. Clin Pharmacokinet 2020; 58:859-874. [PMID: 30758736 PMCID: PMC6584251 DOI: 10.1007/s40262-019-00742-8] [Citation(s) in RCA: 77] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Eculizumab is the first drug approved for the treatment of complement-mediated diseases, and current dosage schedules result in large interindividual drug concentrations. This review provides insight into the pharmacokinetic and pharmacodynamic properties of eculizumab, both for reported on-label (paroxysmal nocturnal hemoglobinuria, atypical hemolytic uremic syndrome, generalized myasthenia gravis) and off-label (hematopoietic stem cell transplantation-associated thrombotic microangiopathy) indications. Furthermore, we discuss the potential of therapeutic drug monitoring to individualize treatment and reduce costs.
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30
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Berciano J. Axonal degeneration in Guillain-Barré syndrome: a reappraisal. J Neurol 2020; 268:3728-3743. [PMID: 32607643 DOI: 10.1007/s00415-020-10034-y] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Revised: 06/24/2020] [Accepted: 06/26/2020] [Indexed: 11/28/2022]
Abstract
The aim of this review was to analyse the pathophysiology of axonal degeneration in Guillain-Barré syndrome (GBS) with emphasis on early stages (≤ 10 days after onset). An overview of experimental autoimmune neuritis (EAN) models is provided. Originally GBS and acute inflammatory demyelinating polyneuropathy were equated, presence of axonal degeneration being attributed to a "bystander" effect. Afterwards, primary axonal GBS forms were reported, designated as acute motor axonal neuropathy/acute motor-sensory axonal neuropathy. Revision of the first pathological description of axonal GBS indicates the coexistence of active axonal degeneration and demyelination in spinal roots, and pure Wallerian-like degeneration in peripheral nerve trunks. Nerve conduction studies are essential for syndrome subtyping, though their sensitivity is scanty in early GBS. Serum markers of axonal degeneration include increased levels of neurofilament light chain and presence of anti-ganglioside reactivity. According to nerve ultrasonographic features and autopsy studies, ventral rami of spinal nerves are a hotspot in early GBS. In P2-induced EAN models, the initial pathogenic change is inflammatory oedema of spinal roots and sciatic nerve, which is followed by demyelination, and Wallerian-like degeneration in nerve trunks possessing epi-perineurium; a critical elevation of endoneurial fluid pressure is a pre-requisite for inducing ischemic axonal degeneration. Similar lesion topography may occur in GBS. The repairing role of adaxonal Schwann cytoplasm in axonal degeneration is analysed. A novel pathophysiological mechanism for nerve trunk pain in GBS, including pure motor forms, is provided. The potential therapeutic role of intravenous boluses of methylprednisolone for early severe GBS and intractable pain is argued.
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Affiliation(s)
- José Berciano
- Professor Emeritus of Neurology, Service of Neurology, University Hospital "Marqués de Valdecilla (IDIVAL)", "Centro de Investigación Biomédica en Red de Enfermedades Neurodegenerativas (CIBERNED)", University of Cantabria, Santander, Spain.
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31
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Abstract
Guillain-Barré Syndrome (GBS) is an acute monophasic immune-mediated neuropathy, generally considered to be of good prognosis. However, 15-20% of GBS patients cannot walk independently at six months from onset. Poor prognostic factors for long-term functional disability included old age, preceding diarrhea, muscle weakness on admission and on day 7 from admission, severe GBS disability score at two weeks from admission and IgG antibody against GD1a/GD1b ganglioside complex. Factors related with requirement of mechanical ventilation included the time from onset to admission <7 days, muscle weakness on admission, facial and/or bulbar weakness and IgG antibody against GQ1b. Recently modified Erasmus GBS outcome score (mEGOS) and Erasmus GBS respiratory insufficiency score (EGRIS) were reported as prognostic factors for the long-term functional disability and respiratory insufficiency. Those were designed on Dutch patients. The usefulness of these tools in Japan or other countries remained unknown. The authors validated mEGOS and EGRIS on Japanese GBS patients in Japanese GBS outcome study, which revealed that these tools were also adaptable on Japanese GBS patients. To identify clinical and biological factors of GBS in more detail, such a large scale prospective study as International GBS outcome study (IGOS) is warranted.
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Affiliation(s)
- Yuko Yamagishi
- Department of Neurology, Kindai University, Faculty of Medicine
| | - Susumu Kusunoki
- Department of Neurology, Kindai University, Faculty of Medicine
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Furukawa K, Ohmi Y, Yesmin F, Tajima O, Kondo Y, Zhang P, Hashimoto N, Ohkawa Y, Bhuiyan RH, Furukawa K. Novel Molecular Mechanisms of Gangliosides in the Nervous System Elucidated by Genetic Engineering. Int J Mol Sci 2020; 21:ijms21061906. [PMID: 32168753 PMCID: PMC7139306 DOI: 10.3390/ijms21061906] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Revised: 02/29/2020] [Accepted: 03/06/2020] [Indexed: 12/13/2022] Open
Abstract
Acidic glycosphingolipids, i.e., gangliosides, are predominantly and consistently expressed in nervous tissues of vertebrates at high levels. Therefore, they are considered to be involved in the development and function of nervous systems. Recent studies involving genetic engineering of glycosyltransferase genes have revealed novel aspects of the roles of gangliosides in the regulation of nervous tissues. In this review, novel findings regarding ganglioside functions and their modes of action elucidated mainly by studies of gene knockout mice are summarized. In particular, the roles of gangliosides in the regulation of lipid rafts to maintain the integrity of nervous systems are reported with a focus on the roles in the regulation of neuro-inflammation and neurodegeneration via complement systems. In addition, recent advances in studies of congenital neurological disorders due to genetic mutations of ganglioside synthase genes and also in the techniques for the analysis of ganglioside functions are introduced.
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Affiliation(s)
- Koichi Furukawa
- Department of Biomedical Sciences, Chubu University College of Life and Health Sciences, 1200 Matsumoto, Kasugai, Aichi 487-8501, Japan; (F.Y.); (O.T.); (P.Z.); (R.H.B.); (K.F.)
- Department of Biochemistry II, Nagoya University Graduate School of Medicine, 65 Tsurumai, Showa-ku, Nagoya 466-0065, Japan;
- Correspondence: ; Tel./Fax: +81-568-51-9512
| | - Yuhsuke Ohmi
- Department of Medical Technology, Chubu University College of Life and Health Sciences, 1200 Matsumoto, Kasugai, Aichi 487-8501, Japan;
| | - Farhana Yesmin
- Department of Biomedical Sciences, Chubu University College of Life and Health Sciences, 1200 Matsumoto, Kasugai, Aichi 487-8501, Japan; (F.Y.); (O.T.); (P.Z.); (R.H.B.); (K.F.)
- Department of Biochemistry II, Nagoya University Graduate School of Medicine, 65 Tsurumai, Showa-ku, Nagoya 466-0065, Japan;
| | - Orie Tajima
- Department of Biomedical Sciences, Chubu University College of Life and Health Sciences, 1200 Matsumoto, Kasugai, Aichi 487-8501, Japan; (F.Y.); (O.T.); (P.Z.); (R.H.B.); (K.F.)
| | - Yuji Kondo
- Department of Biochemistry II, Nagoya University Graduate School of Medicine, 65 Tsurumai, Showa-ku, Nagoya 466-0065, Japan;
| | - Pu Zhang
- Department of Biomedical Sciences, Chubu University College of Life and Health Sciences, 1200 Matsumoto, Kasugai, Aichi 487-8501, Japan; (F.Y.); (O.T.); (P.Z.); (R.H.B.); (K.F.)
- Department of Biochemistry II, Nagoya University Graduate School of Medicine, 65 Tsurumai, Showa-ku, Nagoya 466-0065, Japan;
| | - Noboru Hashimoto
- Department of Tissue Regeneration, Tokushima University Graduate School of Biomedical Sciences, 3-18-5, Kuramoto-cho, Tokushima 770-8504, Japan;
| | - Yuki Ohkawa
- Department of Glycooncology, Osaka International Cancer Institute, Osaka 541-8567, Japan;
| | - Robiul H. Bhuiyan
- Department of Biomedical Sciences, Chubu University College of Life and Health Sciences, 1200 Matsumoto, Kasugai, Aichi 487-8501, Japan; (F.Y.); (O.T.); (P.Z.); (R.H.B.); (K.F.)
| | - Keiko Furukawa
- Department of Biomedical Sciences, Chubu University College of Life and Health Sciences, 1200 Matsumoto, Kasugai, Aichi 487-8501, Japan; (F.Y.); (O.T.); (P.Z.); (R.H.B.); (K.F.)
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Korinthenberg R, Trollmann R, Felderhoff-Müser U, Bernert G, Hackenberg A, Hufnagel M, Pohl M, Hahn G, Mentzel HJ, Sommer C, Lambeck J, Mecher F, Hessenauer M, Winterholler C, Kempf U, Jacobs BC, Rostasy K, Müller-Felber W. Diagnosis and treatment of Guillain-Barré Syndrome in childhood and adolescence: An evidence- and consensus-based guideline. Eur J Paediatr Neurol 2020; 25:5-16. [PMID: 31941581 DOI: 10.1016/j.ejpn.2020.01.003] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Revised: 12/27/2019] [Accepted: 01/03/2020] [Indexed: 12/22/2022]
Abstract
This evidence- and consensus-based practical guideline for the diagnosis and treatment of Guillain-Barré Syndrome (GBS) in childhood and adolescence has been developed by a group of delegates from relevant specialist societies and organisations; it is the result of an initiative by the German-Speaking Society of Neuropediatrics (GNP), and is supported by the Association of Scientific Medical Societies (AWMF, Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften). A systematic analysis of the literature revealed that only a few adequately-controlled studies exist for this particular age group, while none carries a low risk of bias. For this reason, the diagnostic and therapeutic recommendations largely rely on findings in adult patients with GBS, for which there are a higher number of suitable studies available. Consensus was established using a written, multi-step Delphi process. A high level of consensus could be reached for the crucial steps in diagnosis and treatment. We recommend basing the diagnostic approach on the clinical criteria of GBS and deriving support from CSF and electrophysiological findings. Repetition of invasive procedures that yield ambiguous results is only recommended if the diagnosis cannot be ascertained from the other criteria. For severe or persistently-progressive GBS treatment with intravenous immunoglobulin (IVIG) is recommended, whereas in cases of IVIG intolerance or inefficacy we recommended treatment with plasmapheresis. Corticosteroids are ineffective for GBS but can be considered when acute onset chronic inflammatory demyelinating polyneuropathy (A-CIDP) is suspected due to a prolonged disease course. The full German version of the Guideline is available on the AWMF website (https://www.awmf.org/leitlinien/detail/ll/022-008.html).
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Affiliation(s)
- R Korinthenberg
- Division of Neuropediatrics and Muscular Disorders, Department of Pediatrics and Adolescent Medicine, Faculty of Medicine, University Medical Center (UMC), University of Freiburg, Germany.
| | - R Trollmann
- Department of Neuropediatrics, UMC, Friedrich- Alexander University Erlangen-Nürnberg, Erlangen, Germany
| | | | - G Bernert
- Department of Pediatrics, Kaiser-Franz-Joseph-Hospital with Preyer's Childrens Hospital, Vienna, Austria
| | - A Hackenberg
- Department of Pediatric Neurology, University Children's Hospital, Zürich, Switzerland
| | - M Hufnagel
- Division of Pediatric Infectious Diseases and Rheumatology, Department of Pediatrics and Adolescent Medicine, Faculty of Medicine, UMC, University of Freiburg, Germany
| | - M Pohl
- Section Pediatric Nephrology, Department of Pediatrics and Adolescent Medicine, Faculty of Medicine, UMC, University of Freiburg, Germany
| | - G Hahn
- Department of Radiological Diagnostics, UMC, University of Dresden, Germany
| | - H J Mentzel
- Section Pediatric Radiology, Institute of Diagnostic and Interventional Radiology, Universitätsklinikum Jena, Germany
| | - C Sommer
- Department of Neurology, UMC, University of Wuerzburg, Germany
| | - J Lambeck
- Department of Neurology and Neurophysiology, UMC, University of Freiburg, Germany
| | - F Mecher
- Physio Deutschland, German Federal Association for Physiotherapy, Germany
| | - M Hessenauer
- Centre for Pediatric Neurology, Neurorehabilitation and Epileptology, Schoen Clinic Vogtareuth, Germany
| | - C Winterholler
- German Federal Association of Logopedics (dbl e.V. Deutscher Bundesverband für Logopädie e.v), Germany
| | - U Kempf
- Mother of a GBS PPatient, Kraichtal-Neuenbürg, Germany
| | - B C Jacobs
- Departments of Neurology and Immunology, Erasmus MC, UMC Rotterdam, the Netherlands
| | - K Rostasy
- Department of Neuropediatrics, Children´s Hospital Datteln, University Witten/Herdecke, Germany
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Verboon C, van den Berg B, Cornblath DR, Venema E, Gorson KC, Lunn MP, Lingsma H, Van den Bergh P, Harbo T, Bateman K, Pereon Y, Sindrup SH, Kusunoki S, Miller J, Islam Z, Hartung HP, Chavada G, Jacobs BC, Hughes RAC, van Doorn PA. Original research: Second IVIg course in Guillain-Barré syndrome with poor prognosis: the non-randomised ISID study. J Neurol Neurosurg Psychiatry 2020; 91:113-121. [PMID: 31586949 DOI: 10.1136/jnnp-2019-321496] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Revised: 08/20/2019] [Accepted: 09/18/2019] [Indexed: 12/29/2022]
Abstract
OBJECTIVE To compare disease course in patients with Guillain-Barré syndrome (GBS) with a poor prognosis who were treated with one or with two intravenous immunoglobulin (IVIg) courses. METHODS From the International GBS Outcome Study, we selected patients whose modified Erasmus GBS Outcome Score at week 1 predicted a poor prognosis. We compared those treated with one IVIg course to those treated with two IVIg courses. The primary endpoint, the GBS disability scale at 4 weeks, was assessed with multivariable ordinal regression. RESULTS Of 237 eligible patients, 199 patients received a single IVIg course. Twenty patients received an 'early' second IVIg course (1-2 weeks after start of the first IVIg course) and 18 patients a 'late' second IVIg course (2-4 weeks after start of IVIg). At baseline and 1 week, those receiving two IVIg courses were more disabled than those receiving one course. Compared with the one course group, the adjusted OR for a better GBS disability score at 4 weeks was 0.70 (95%CI 0.16 to 3.04) for the early group and 0.66 (95%CI 0.18 to 2.50) for the late group. The secondary endpoints were not in favour of a second IVIg course. CONCLUSIONS This observational study did not show better outcomes after a second IVIg course in GBS with poor prognosis. The study was limited by small numbers and baseline imbalances. Lack of improvement was likely an incentive to start a second IVIg course. A prospective randomised trial is needed to evaluate whether a second IVIg course improves outcome in GBS.
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Affiliation(s)
| | | | - David R Cornblath
- Department of Neurology, Johns Hopkins University, Baltimore, Maryland, USA
| | - Esmee Venema
- Department of Neurology, Erasmus MC, Rotterdam, The Netherlands.,Department of Public Health, Erasmus MC, Rotterdam, The Netherlands
| | - Kenneth C Gorson
- Department of Neurology, St. Elizabeth's Medical Center, Boston, Massachusetts, USA
| | - Michael P Lunn
- Department of Neurology, National Hospital for Neurology and Neurosurgery, London, UK
| | - Hester Lingsma
- Department of Public Health, Erasmus MC, Rotterdam, The Netherlands
| | | | - Thomas Harbo
- Department of Neurology, Aarhus University Hospital, Aarhus, Denmark
| | - Kathleen Bateman
- Department of Neurology, University of Cape Town, Cape Town, South Africa
| | - Yann Pereon
- Department of Clinical Neurophysiology, Reference Centre for NMD, Nantes University Hospital, Nantes, France
| | - Søren H Sindrup
- Department of Neurology, Odense University Hospital, Odense, Denmark
| | - Susumu Kusunoki
- Department of Neurology, Kindai University Faculty of Medicine, Osaka, Japan
| | - James Miller
- Department of Neurology, Royal Victoria Infirmary, Newcastle, UK
| | - Zhahirul Islam
- Department of Laboratory Sciences and Services Division, The International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
| | | | | | - Bart C Jacobs
- Department of Neurology, Erasmus MC, Rotterdam, The Netherlands.,Department of Immunology, Erasmus MC, Rotterdam, The Netherlands
| | - Richard A C Hughes
- MRC Centre for Neuromuscular Diseases, National Hospital for Neurology and Neurosurgery, London, UK
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Doets AY, Hughes RAC, Brassington R, Hadden RDM, Pritchard J. Pharmacological treatment other than corticosteroids, intravenous immunoglobulin and plasma exchange for Guillain-Barré syndrome. Cochrane Database Syst Rev 2020; 1:CD008630. [PMID: 31981368 PMCID: PMC6984651 DOI: 10.1002/14651858.cd008630.pub5] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Plasma exchange and intravenous immunoglobulin, but not corticosteroids, are beneficial in Guillain-Barré syndrome (GBS). The efficacy of other pharmacological agents is unknown. This review was first published in 2011 and previously updated in 2013, and 2016. OBJECTIVES To assess the effects of pharmacological agents other than plasma exchange, intravenous immunoglobulin and corticosteroids for GBS. SEARCH METHODS On 28 October 2019, we searched the Cochrane Neuromuscular Specialised Register, CENTRAL, MEDLINE, and Embase for treatments for GBS. We also searched clinical trials registries. SELECTION CRITERIA We included all randomised controlled trials (RCTs) or quasi-RCTs of acute GBS (within four weeks from onset) of all types and degrees of severity, and in individuals of all ages. We discarded trials that investigated only corticosteroids, intravenous immunoglobulin or plasma exchange. We included other pharmacological treatments or combinations of treatments compared with no treatment, placebo or another treatment. DATA COLLECTION AND ANALYSIS We followed standard Cochrane methodology. MAIN RESULTS We found six trials of five different interventions eligible for inclusion in this review. The trials were conducted in hospitals in Canada, China, Germany, Japan and the UK, and included 151 participants in total. All trials randomised participants aged 16 years and older (mean or median age in the trials ranged from 36 to 57 years in the intervention groups and 34 to 60 years in the control groups) with severe GBS, defined by the inability to walk unaided. One trial also randomised patients with mild GBS who were still able to walk unaided. We identified two new trials at this update.The primary outcome measure for this review was improvement in disability grade four weeks after randomisation. Four of six trials had a high risk of bias in at least one respect. We assessed all evidence for the outcome mean improvement in disability grade as very low certainty, which means that we were unable to draw any conclusions from the data. One RCT with 19 participants compared interferon beta-1a (IFNb-1a) and placebo. It is uncertain whether IFNb-1a improves disability after four weeks (mean difference (MD) -0.1; 95% CI -1.58 to 1.38; very low-certainty evidence). A trial with 10 participants compared brain-derived neurotrophic factor (BNDF) and placebo. It is uncertain whether BDNF improves disability after four weeks (MD 0.75; 95% CI -1.14 to 2.64; very low-certainty evidence). A trial with 37 participants compared cerebrospinal fluid (CSF) filtration and plasma exchange. It is uncertain whether CSF filtration improves disability after four weeks (MD 0.02; 95% CI -0.62 to 0.66; very low-certainty evidence). One trial that compared the Chinese herbal medicine tripterygium polyglycoside with corticosteroids with 43 participants did not report the risk ratio (RR) for an improvement by one or more disability grade after four weeks, but did report improvement after eight weeks. It is uncertain whether tripterygium polyglycoside improves disability after eight weeks (RR 1.47; 95% CI 1.02 to 2.11; very low-certainty evidence). We performed a meta-analysis of two trials comparing eculizumab and placebo with 41 participants. It is uncertain whether eculizumab improves disability after four weeks (MD -0.23; 95% CI -1.79 to 1.34; very low-certainty evidence). Serious adverse events were uncommon in each of the trials and evidence was graded as either low or very low. It is uncertain whether serious adverse events were more common with IFNb-1a versus placebo (RR 0.92, 95% CI 0.23 to 3.72; 19 participants), BNDF versus placebo (RR 1.00, 95% CI 0.28 to 3.54; 10 participants) or CSF filtration versus plasma exchange (RR 0.13, 95% CI 0.01 to 2.25; 37 participants). The trial of tripterygium polyglycoside did not report serious adverse events. There may be no clear difference in the number of serious adverse events after eculizumab compared to placebo (RR 1.90, 0.34 to 10.50; 41 participants). We found no clinically important differences in any of the outcome measures selected for this review in any of the six trials. However, sample sizes were small and therefore clinically important benefit or harm cannot be excluded. AUTHORS' CONCLUSIONS All six RCTs were too small to exclude clinically important benefit or harm from the assessed interventions. The certainty of the evidence was low or very low for all interventions and outcomes.
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Affiliation(s)
- Alex Y Doets
- Erasmus University Medical CentreP.O. Box 2040University Medical Centre RotterdamRotterdamNetherlands3000 CA
| | - Richard AC Hughes
- National Hospital for Neurology and NeurosurgeryMRC Centre for Neuromuscular DiseasesPO Box 114Queen SquareLondonUKWC1N 3BG
| | - Ruth Brassington
- National Hospital for Neurology and NeurosurgeryQueen Square Centre for Neuromuscular DiseasesPO Box 114LondonUKWC1N 3BG
| | - Robert DM Hadden
- King's College HospitalDepartment of NeurologyDenmark HillLondonUKSE5 9RS
| | - Jane Pritchard
- Charing Cross HospitalNeuromuscular Unit 3 NorthFulham Palace RoadLondonUKW6 8RF
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Abstract
PURPOSE OF REVIEW This article will update and review the Miller Fisher variants (MFV) of Guillain-Barré syndrome (GBS) including the clinical presentation, diagnostic testing, and treatment. RECENT FINDINGS Although the diagnosis of GBS and MFV can be made on clinical grounds, cerebrospinal fluid (CSF) analysis, nerve conduction studies, imaging (e.g. ultrasound and MRI), and serologic testing can help to confirm the diagnosis. Some patients may need immunotherapy with either intravenous immunoglobulin (IVIg) or plasma exchange, and recent studies suggest that complement inhibition combined with IVIg could be of benefit, but further studies are needed to prove efficacy. SUMMARY GBS is characterized by an acute, ascending polyneuropathy, ataxia, areflexia, and CSF albuminocytologic dissociation. The MFV of GBS is associated with ophthalmoplegia. Clinicians should have high index of suspicion for MFV of GBS in patients with acute ophthalmoplegia in order to establish the diagnosis, perform appropriate evaluation, and start treatment. SDC VIDEO LINK:.
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Verboon C, Doets AY, Galassi G, Davidson A, Waheed W, Péréon Y, Shahrizaila N, Kusunoki S, Lehmann HC, Harbo T, Monges S, Van den Bergh P, Willison HJ, Cornblath DR, Jacobs BC. Current treatment practice of Guillain-Barré syndrome. Neurology 2019; 93:e59-e76. [PMID: 31175208 DOI: 10.1212/wnl.0000000000007719] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2018] [Accepted: 02/13/2019] [Indexed: 01/08/2023] Open
Abstract
OBJECTIVE To define the current treatment practice of Guillain-Barré syndrome (GBS). METHODS The study was based on prospective observational data from the first 1,300 patients included in the International GBS Outcome Study. We described the treatment practice of GBS in general, and for (1) severe forms (unable to walk independently), (2) no recovery after initial treatment, (3) treatment-related fluctuations, (4) mild forms (able to walk independently), and (5) variant forms including Miller Fisher syndrome, taking patient characteristics and hospital type into account. RESULTS We excluded 88 (7%) patients because of missing data, protocol violation, or alternative diagnosis. Patients from Bangladesh (n = 189, 15%) were described separately because 83% were not treated. IV immunoglobulin (IVIg), plasma exchange (PE), or other immunotherapy was provided in 941 (92%) of the remaining 1,023 patients, including patients with severe GBS (724/743, 97%), mild GBS (126/168, 75%), Miller Fisher syndrome (53/70, 76%), and other variants (33/40, 83%). Of 235 (32%) patients who did not improve after their initial treatment, 82 (35%) received a second immune modulatory treatment. A treatment-related fluctuation was observed in 53 (5%) of 1,023 patients, of whom 36 (68%) were re-treated with IVIg or PE. CONCLUSIONS In current practice, patients with mild and variant forms of GBS, or with treatment-related fluctuations and treatment failures, are frequently treated, even in absence of trial data to support this choice. The variability in treatment practice can be explained in part by the lack of evidence and guidelines for effective treatment in these situations.
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Affiliation(s)
- Christine Verboon
- From the Departments of Neurology (C.V., A.Y.D., B.C.J.) and Immunology (B.C.J.), Erasmus MC, University Medical Center Rotterdam, the Netherlands; Department of Neurology (G.G.), University Hospital of Modena, Italy; Department of Neurology (A.D., H.J.W.), University of Glasgow, UK; Department of Neurology (W.W.), University of Vermont Medical Center, Burlington; Department of Clinical Neurophysiology (Y.P.), Reference Centre for NMD, Nantes University Hospital, France; Department of Medicine (N.S.), University of Malaya, Kuala Lumpur, Malaysia; Department of Neurology (S.K.), Kindai University Faculty of Medicine, Osaka, Japan; Department of Neurology (H.C.L.), Universitätsklinikum Köln, Germany; Department of Neurology (T.H.), Aarhus University Hospital, Denmark; Department of Neurology (S.M.), Hospital de Pediatría J.P. Garrahan, Buenos Aires, Argentina; Department of Neurology (P.V.d.B.), University Hospital St-Luc, University of Louvain, Brussels, Belgium; and Department of Neurology (D.R.C.), Johns Hopkins University School of Medicine, Baltimore, MD
| | - Alex Y Doets
- From the Departments of Neurology (C.V., A.Y.D., B.C.J.) and Immunology (B.C.J.), Erasmus MC, University Medical Center Rotterdam, the Netherlands; Department of Neurology (G.G.), University Hospital of Modena, Italy; Department of Neurology (A.D., H.J.W.), University of Glasgow, UK; Department of Neurology (W.W.), University of Vermont Medical Center, Burlington; Department of Clinical Neurophysiology (Y.P.), Reference Centre for NMD, Nantes University Hospital, France; Department of Medicine (N.S.), University of Malaya, Kuala Lumpur, Malaysia; Department of Neurology (S.K.), Kindai University Faculty of Medicine, Osaka, Japan; Department of Neurology (H.C.L.), Universitätsklinikum Köln, Germany; Department of Neurology (T.H.), Aarhus University Hospital, Denmark; Department of Neurology (S.M.), Hospital de Pediatría J.P. Garrahan, Buenos Aires, Argentina; Department of Neurology (P.V.d.B.), University Hospital St-Luc, University of Louvain, Brussels, Belgium; and Department of Neurology (D.R.C.), Johns Hopkins University School of Medicine, Baltimore, MD
| | - Giuliana Galassi
- From the Departments of Neurology (C.V., A.Y.D., B.C.J.) and Immunology (B.C.J.), Erasmus MC, University Medical Center Rotterdam, the Netherlands; Department of Neurology (G.G.), University Hospital of Modena, Italy; Department of Neurology (A.D., H.J.W.), University of Glasgow, UK; Department of Neurology (W.W.), University of Vermont Medical Center, Burlington; Department of Clinical Neurophysiology (Y.P.), Reference Centre for NMD, Nantes University Hospital, France; Department of Medicine (N.S.), University of Malaya, Kuala Lumpur, Malaysia; Department of Neurology (S.K.), Kindai University Faculty of Medicine, Osaka, Japan; Department of Neurology (H.C.L.), Universitätsklinikum Köln, Germany; Department of Neurology (T.H.), Aarhus University Hospital, Denmark; Department of Neurology (S.M.), Hospital de Pediatría J.P. Garrahan, Buenos Aires, Argentina; Department of Neurology (P.V.d.B.), University Hospital St-Luc, University of Louvain, Brussels, Belgium; and Department of Neurology (D.R.C.), Johns Hopkins University School of Medicine, Baltimore, MD
| | - Amy Davidson
- From the Departments of Neurology (C.V., A.Y.D., B.C.J.) and Immunology (B.C.J.), Erasmus MC, University Medical Center Rotterdam, the Netherlands; Department of Neurology (G.G.), University Hospital of Modena, Italy; Department of Neurology (A.D., H.J.W.), University of Glasgow, UK; Department of Neurology (W.W.), University of Vermont Medical Center, Burlington; Department of Clinical Neurophysiology (Y.P.), Reference Centre for NMD, Nantes University Hospital, France; Department of Medicine (N.S.), University of Malaya, Kuala Lumpur, Malaysia; Department of Neurology (S.K.), Kindai University Faculty of Medicine, Osaka, Japan; Department of Neurology (H.C.L.), Universitätsklinikum Köln, Germany; Department of Neurology (T.H.), Aarhus University Hospital, Denmark; Department of Neurology (S.M.), Hospital de Pediatría J.P. Garrahan, Buenos Aires, Argentina; Department of Neurology (P.V.d.B.), University Hospital St-Luc, University of Louvain, Brussels, Belgium; and Department of Neurology (D.R.C.), Johns Hopkins University School of Medicine, Baltimore, MD
| | - Waqar Waheed
- From the Departments of Neurology (C.V., A.Y.D., B.C.J.) and Immunology (B.C.J.), Erasmus MC, University Medical Center Rotterdam, the Netherlands; Department of Neurology (G.G.), University Hospital of Modena, Italy; Department of Neurology (A.D., H.J.W.), University of Glasgow, UK; Department of Neurology (W.W.), University of Vermont Medical Center, Burlington; Department of Clinical Neurophysiology (Y.P.), Reference Centre for NMD, Nantes University Hospital, France; Department of Medicine (N.S.), University of Malaya, Kuala Lumpur, Malaysia; Department of Neurology (S.K.), Kindai University Faculty of Medicine, Osaka, Japan; Department of Neurology (H.C.L.), Universitätsklinikum Köln, Germany; Department of Neurology (T.H.), Aarhus University Hospital, Denmark; Department of Neurology (S.M.), Hospital de Pediatría J.P. Garrahan, Buenos Aires, Argentina; Department of Neurology (P.V.d.B.), University Hospital St-Luc, University of Louvain, Brussels, Belgium; and Department of Neurology (D.R.C.), Johns Hopkins University School of Medicine, Baltimore, MD
| | - Yann Péréon
- From the Departments of Neurology (C.V., A.Y.D., B.C.J.) and Immunology (B.C.J.), Erasmus MC, University Medical Center Rotterdam, the Netherlands; Department of Neurology (G.G.), University Hospital of Modena, Italy; Department of Neurology (A.D., H.J.W.), University of Glasgow, UK; Department of Neurology (W.W.), University of Vermont Medical Center, Burlington; Department of Clinical Neurophysiology (Y.P.), Reference Centre for NMD, Nantes University Hospital, France; Department of Medicine (N.S.), University of Malaya, Kuala Lumpur, Malaysia; Department of Neurology (S.K.), Kindai University Faculty of Medicine, Osaka, Japan; Department of Neurology (H.C.L.), Universitätsklinikum Köln, Germany; Department of Neurology (T.H.), Aarhus University Hospital, Denmark; Department of Neurology (S.M.), Hospital de Pediatría J.P. Garrahan, Buenos Aires, Argentina; Department of Neurology (P.V.d.B.), University Hospital St-Luc, University of Louvain, Brussels, Belgium; and Department of Neurology (D.R.C.), Johns Hopkins University School of Medicine, Baltimore, MD
| | - Nortina Shahrizaila
- From the Departments of Neurology (C.V., A.Y.D., B.C.J.) and Immunology (B.C.J.), Erasmus MC, University Medical Center Rotterdam, the Netherlands; Department of Neurology (G.G.), University Hospital of Modena, Italy; Department of Neurology (A.D., H.J.W.), University of Glasgow, UK; Department of Neurology (W.W.), University of Vermont Medical Center, Burlington; Department of Clinical Neurophysiology (Y.P.), Reference Centre for NMD, Nantes University Hospital, France; Department of Medicine (N.S.), University of Malaya, Kuala Lumpur, Malaysia; Department of Neurology (S.K.), Kindai University Faculty of Medicine, Osaka, Japan; Department of Neurology (H.C.L.), Universitätsklinikum Köln, Germany; Department of Neurology (T.H.), Aarhus University Hospital, Denmark; Department of Neurology (S.M.), Hospital de Pediatría J.P. Garrahan, Buenos Aires, Argentina; Department of Neurology (P.V.d.B.), University Hospital St-Luc, University of Louvain, Brussels, Belgium; and Department of Neurology (D.R.C.), Johns Hopkins University School of Medicine, Baltimore, MD
| | - Susumu Kusunoki
- From the Departments of Neurology (C.V., A.Y.D., B.C.J.) and Immunology (B.C.J.), Erasmus MC, University Medical Center Rotterdam, the Netherlands; Department of Neurology (G.G.), University Hospital of Modena, Italy; Department of Neurology (A.D., H.J.W.), University of Glasgow, UK; Department of Neurology (W.W.), University of Vermont Medical Center, Burlington; Department of Clinical Neurophysiology (Y.P.), Reference Centre for NMD, Nantes University Hospital, France; Department of Medicine (N.S.), University of Malaya, Kuala Lumpur, Malaysia; Department of Neurology (S.K.), Kindai University Faculty of Medicine, Osaka, Japan; Department of Neurology (H.C.L.), Universitätsklinikum Köln, Germany; Department of Neurology (T.H.), Aarhus University Hospital, Denmark; Department of Neurology (S.M.), Hospital de Pediatría J.P. Garrahan, Buenos Aires, Argentina; Department of Neurology (P.V.d.B.), University Hospital St-Luc, University of Louvain, Brussels, Belgium; and Department of Neurology (D.R.C.), Johns Hopkins University School of Medicine, Baltimore, MD
| | - Helmar C Lehmann
- From the Departments of Neurology (C.V., A.Y.D., B.C.J.) and Immunology (B.C.J.), Erasmus MC, University Medical Center Rotterdam, the Netherlands; Department of Neurology (G.G.), University Hospital of Modena, Italy; Department of Neurology (A.D., H.J.W.), University of Glasgow, UK; Department of Neurology (W.W.), University of Vermont Medical Center, Burlington; Department of Clinical Neurophysiology (Y.P.), Reference Centre for NMD, Nantes University Hospital, France; Department of Medicine (N.S.), University of Malaya, Kuala Lumpur, Malaysia; Department of Neurology (S.K.), Kindai University Faculty of Medicine, Osaka, Japan; Department of Neurology (H.C.L.), Universitätsklinikum Köln, Germany; Department of Neurology (T.H.), Aarhus University Hospital, Denmark; Department of Neurology (S.M.), Hospital de Pediatría J.P. Garrahan, Buenos Aires, Argentina; Department of Neurology (P.V.d.B.), University Hospital St-Luc, University of Louvain, Brussels, Belgium; and Department of Neurology (D.R.C.), Johns Hopkins University School of Medicine, Baltimore, MD
| | - Thomas Harbo
- From the Departments of Neurology (C.V., A.Y.D., B.C.J.) and Immunology (B.C.J.), Erasmus MC, University Medical Center Rotterdam, the Netherlands; Department of Neurology (G.G.), University Hospital of Modena, Italy; Department of Neurology (A.D., H.J.W.), University of Glasgow, UK; Department of Neurology (W.W.), University of Vermont Medical Center, Burlington; Department of Clinical Neurophysiology (Y.P.), Reference Centre for NMD, Nantes University Hospital, France; Department of Medicine (N.S.), University of Malaya, Kuala Lumpur, Malaysia; Department of Neurology (S.K.), Kindai University Faculty of Medicine, Osaka, Japan; Department of Neurology (H.C.L.), Universitätsklinikum Köln, Germany; Department of Neurology (T.H.), Aarhus University Hospital, Denmark; Department of Neurology (S.M.), Hospital de Pediatría J.P. Garrahan, Buenos Aires, Argentina; Department of Neurology (P.V.d.B.), University Hospital St-Luc, University of Louvain, Brussels, Belgium; and Department of Neurology (D.R.C.), Johns Hopkins University School of Medicine, Baltimore, MD
| | - Soledad Monges
- From the Departments of Neurology (C.V., A.Y.D., B.C.J.) and Immunology (B.C.J.), Erasmus MC, University Medical Center Rotterdam, the Netherlands; Department of Neurology (G.G.), University Hospital of Modena, Italy; Department of Neurology (A.D., H.J.W.), University of Glasgow, UK; Department of Neurology (W.W.), University of Vermont Medical Center, Burlington; Department of Clinical Neurophysiology (Y.P.), Reference Centre for NMD, Nantes University Hospital, France; Department of Medicine (N.S.), University of Malaya, Kuala Lumpur, Malaysia; Department of Neurology (S.K.), Kindai University Faculty of Medicine, Osaka, Japan; Department of Neurology (H.C.L.), Universitätsklinikum Köln, Germany; Department of Neurology (T.H.), Aarhus University Hospital, Denmark; Department of Neurology (S.M.), Hospital de Pediatría J.P. Garrahan, Buenos Aires, Argentina; Department of Neurology (P.V.d.B.), University Hospital St-Luc, University of Louvain, Brussels, Belgium; and Department of Neurology (D.R.C.), Johns Hopkins University School of Medicine, Baltimore, MD
| | - Peter Van den Bergh
- From the Departments of Neurology (C.V., A.Y.D., B.C.J.) and Immunology (B.C.J.), Erasmus MC, University Medical Center Rotterdam, the Netherlands; Department of Neurology (G.G.), University Hospital of Modena, Italy; Department of Neurology (A.D., H.J.W.), University of Glasgow, UK; Department of Neurology (W.W.), University of Vermont Medical Center, Burlington; Department of Clinical Neurophysiology (Y.P.), Reference Centre for NMD, Nantes University Hospital, France; Department of Medicine (N.S.), University of Malaya, Kuala Lumpur, Malaysia; Department of Neurology (S.K.), Kindai University Faculty of Medicine, Osaka, Japan; Department of Neurology (H.C.L.), Universitätsklinikum Köln, Germany; Department of Neurology (T.H.), Aarhus University Hospital, Denmark; Department of Neurology (S.M.), Hospital de Pediatría J.P. Garrahan, Buenos Aires, Argentina; Department of Neurology (P.V.d.B.), University Hospital St-Luc, University of Louvain, Brussels, Belgium; and Department of Neurology (D.R.C.), Johns Hopkins University School of Medicine, Baltimore, MD
| | - Hugh J Willison
- From the Departments of Neurology (C.V., A.Y.D., B.C.J.) and Immunology (B.C.J.), Erasmus MC, University Medical Center Rotterdam, the Netherlands; Department of Neurology (G.G.), University Hospital of Modena, Italy; Department of Neurology (A.D., H.J.W.), University of Glasgow, UK; Department of Neurology (W.W.), University of Vermont Medical Center, Burlington; Department of Clinical Neurophysiology (Y.P.), Reference Centre for NMD, Nantes University Hospital, France; Department of Medicine (N.S.), University of Malaya, Kuala Lumpur, Malaysia; Department of Neurology (S.K.), Kindai University Faculty of Medicine, Osaka, Japan; Department of Neurology (H.C.L.), Universitätsklinikum Köln, Germany; Department of Neurology (T.H.), Aarhus University Hospital, Denmark; Department of Neurology (S.M.), Hospital de Pediatría J.P. Garrahan, Buenos Aires, Argentina; Department of Neurology (P.V.d.B.), University Hospital St-Luc, University of Louvain, Brussels, Belgium; and Department of Neurology (D.R.C.), Johns Hopkins University School of Medicine, Baltimore, MD
| | - David R Cornblath
- From the Departments of Neurology (C.V., A.Y.D., B.C.J.) and Immunology (B.C.J.), Erasmus MC, University Medical Center Rotterdam, the Netherlands; Department of Neurology (G.G.), University Hospital of Modena, Italy; Department of Neurology (A.D., H.J.W.), University of Glasgow, UK; Department of Neurology (W.W.), University of Vermont Medical Center, Burlington; Department of Clinical Neurophysiology (Y.P.), Reference Centre for NMD, Nantes University Hospital, France; Department of Medicine (N.S.), University of Malaya, Kuala Lumpur, Malaysia; Department of Neurology (S.K.), Kindai University Faculty of Medicine, Osaka, Japan; Department of Neurology (H.C.L.), Universitätsklinikum Köln, Germany; Department of Neurology (T.H.), Aarhus University Hospital, Denmark; Department of Neurology (S.M.), Hospital de Pediatría J.P. Garrahan, Buenos Aires, Argentina; Department of Neurology (P.V.d.B.), University Hospital St-Luc, University of Louvain, Brussels, Belgium; and Department of Neurology (D.R.C.), Johns Hopkins University School of Medicine, Baltimore, MD
| | - Bart C Jacobs
- From the Departments of Neurology (C.V., A.Y.D., B.C.J.) and Immunology (B.C.J.), Erasmus MC, University Medical Center Rotterdam, the Netherlands; Department of Neurology (G.G.), University Hospital of Modena, Italy; Department of Neurology (A.D., H.J.W.), University of Glasgow, UK; Department of Neurology (W.W.), University of Vermont Medical Center, Burlington; Department of Clinical Neurophysiology (Y.P.), Reference Centre for NMD, Nantes University Hospital, France; Department of Medicine (N.S.), University of Malaya, Kuala Lumpur, Malaysia; Department of Neurology (S.K.), Kindai University Faculty of Medicine, Osaka, Japan; Department of Neurology (H.C.L.), Universitätsklinikum Köln, Germany; Department of Neurology (T.H.), Aarhus University Hospital, Denmark; Department of Neurology (S.M.), Hospital de Pediatría J.P. Garrahan, Buenos Aires, Argentina; Department of Neurology (P.V.d.B.), University Hospital St-Luc, University of Louvain, Brussels, Belgium; and Department of Neurology (D.R.C.), Johns Hopkins University School of Medicine, Baltimore, MD.
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Abstract
PURPOSE OF REVIEW The clinical presentation of Guillain-Barré syndrome (GBS) is highly variable, which can make the diagnosis challenging. Intravenous immunoglobulin (IVIg) and plasma exchange are the cornerstones of treatment since decades. But despite these treatments, 25% initially progress in muscle weakness, 25% require artificial ventilation, 20% is still not able to walk independently after 6 months, and 2-5% die, emphasizing the need for better treatment. We summarize new developments regarding the diagnosis, prognosis, and management of GBS. RECENT FINDINGS GBS is a clinical diagnosis that can be supported by cerebrospinal fluid examination and nerve conduction studies. Nerve ultrasound and MRI are potentially useful techniques to diagnose inflammatory neuropathies. Several novel infections have recently been associated to GBS. Evidence from experimental studies and recent phase 2 clinical trials suggests that complement inhibition combined with IVIg might improve outcome in GBS, but further studies are warranted. Prognostic models could guide the selection of patients with a relatively poor prognosis that might benefit most from additional IVIg or otherwise intensified treatment. SUMMARY New diagnostic tools may help to have early and accurate diagnosis in difficult GBS cases. Increased knowledge on the pathophysiology of GBS forms the basis for development of new, targeted, and personalized treatments that hopefully improve outcome.
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Keller CW, Quast I, Dalakas MC, Lünemann JD. IVIG efficacy in CIDP patients is not associated with terminal complement inhibition. J Neuroimmunol 2019; 330:23-27. [PMID: 30772754 DOI: 10.1016/j.jneuroim.2019.02.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2018] [Revised: 02/05/2019] [Accepted: 02/07/2019] [Indexed: 01/17/2023]
Abstract
Patients with acute and chronic inflammatory demyelinating neuropathies exhibit elevated serum and cerebrospinal fluid (CSF) levels of terminal complement activation products and therapeutic inhibition of complement activation is currently tested for its safety and efficacy in patients with Guillain-Barré syndrome (GBS). Here, we determined serum levels of the complement activation products C3a, C5a and the soluble terminal complement complex (sTCC) in 39 individuals with chronic inflammatory demyelinating polyneuropathy (CIDP) who participated in one of the largest ever conducted clinical trial in patients with CIDP (ICE trial) and received Intravenous Immunoglobulin (IVIG) or placebo (albumin) in 3 week intervals for up to 24 weeks. In placebo-treated patients with spontaneous disease remission, serum sTCC levels moderately decreased over time. Levels of complement activation products were, however, not modulated by IVIG and remained unchanged in patients with a beneficial response to IVIG therapy as compared to those with steady or worsened disease. These results suggest that the therapeutic efficacy of IVIG in CIDP is based on immunomodulatory mechanisms different from complement inhibition. Terminal complement activation merits further investigation as a surrogate marker for disease progression and therapeutic target in patients with CIDP.
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Affiliation(s)
- Christian W Keller
- Department of Neurology with Institute of Translational Neurology, University Hospital Münster, Münster 48149, Germany; Institute of Experimental Immunology, Department of Neuroinflammation, University of Zurich, Zürich 8057, Switzerland
| | - Isaak Quast
- Department of Immunology and Pathology, Central Clinical School, Monash University, Melbourne, Australia
| | - Marinos C Dalakas
- Department of Neurology, Thomas Jefferson University, Philadelphia, USA; Neuroimmunology Unit, Department of Pathophysiology, Faculty of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Jan D Lünemann
- Department of Neurology with Institute of Translational Neurology, University Hospital Münster, Münster 48149, Germany; Institute of Experimental Immunology, Department of Neuroinflammation, University of Zurich, Zürich 8057, Switzerland.
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Abstract
Since the discovery of an acute monophasic paralysis, later coined Guillain-Barré syndrome, almost 100 years ago, and the discovery of chronic, steroid-responsive polyneuropathy 50 years ago, the spectrum of immune-mediated polyneuropathies has broadened, with various subtypes continuing to be identified, including chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) and multifocal motor neuropathy (MMN). In general, these disorders are speculated to be caused by autoimmunity to proteins located at the node of Ranvier or components of myelin of peripheral nerves, although disease-associated autoantibodies have not been identified for all disorders. Owing to the numerous subtypes of the immune-mediated neuropathies, making the right diagnosis in daily clinical practice is complicated. Moreover, treating these disorders, particularly their chronic variants, such as CIDP and MMN, poses a challenge. In general, management of these disorders includes immunotherapies, such as corticosteroids, intravenous immunoglobulin or plasma exchange. Improvements in clinical criteria and the emergence of more disease-specific immunotherapies should broaden the therapeutic options for these disabling diseases.
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Liu S, Dong C, Ubogu EE. Immunotherapy of Guillain-Barré syndrome. Hum Vaccin Immunother 2018; 14:2568-2579. [PMID: 29953326 PMCID: PMC6314401 DOI: 10.1080/21645515.2018.1493415] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Revised: 06/05/2018] [Accepted: 06/21/2018] [Indexed: 12/14/2022] Open
Abstract
Guillain-Barré syndrome (GBS), the most common cause of acute neuromuscular weakness and paralysis worldwide, encompasses a group of acute immune-mediated disorders restricted to peripheral nerves and roots. Immune-mediated attack of peripheral nervous system myelin, axons or both is presumed to be triggered by molecular mimicry, with both cell- and humoral-dependent mechanisms implicated in disease pathogenesis. Good circumstantial evidence exists for a pathogenic role for molecular mimicry in GBS pathogenesis, especially with its axonal forms, providing insights that could guide future immunotherapy. Intravenous immunoglobulin (IVIg) and plasma exchange (PE) are the most commonly prescribed immunotherapies for GBS with variable efficacy dependent on GBS subtype, severity at initial presentation and other clinical and electrophysiologic prognostic factors. The mechanisms of action of IVIg and PE are not known definitely. Despite recent significant advances in molecular biology that provide insights into GBS pathogenesis, no advances in therapeutics or significant improvements in patient outcomes have occurred over the past three decades. We summarize the clinical aspects of GBS, its current pathogenesis and immunotherapy, and highlight the potential of leukocyte trafficking inhibitors as novel disease-specific immunotherapeutic drugs.
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Affiliation(s)
- Shuang Liu
- Neuromuscular Immunopathology Research Laboratory, Division of Neuromuscular Disease, Department of Neurology, University of Alabama at Birmingham, Birmingham, AL, USA
- Division of Neurology, The Second Affiliated Hospital of Tianjin University of Traditional Chinese Medicine, Tianjin, Peoples’ Republic of China
| | - Chaoling Dong
- Neuromuscular Immunopathology Research Laboratory, Division of Neuromuscular Disease, Department of Neurology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Eroboghene Ekamereno Ubogu
- Neuromuscular Immunopathology Research Laboratory, Division of Neuromuscular Disease, Department of Neurology, University of Alabama at Birmingham, Birmingham, AL, USA
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Uncini A, Vallat JM. Autoimmune nodo-paranodopathies of peripheral nerve: the concept is gaining ground. J Neurol Neurosurg Psychiatry 2018; 89:627-635. [PMID: 29248893 DOI: 10.1136/jnnp-2017-317192] [Citation(s) in RCA: 59] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2017] [Revised: 10/15/2017] [Accepted: 11/13/2017] [Indexed: 12/20/2022]
Abstract
Peripheral neuropathies are classified as primarily demyelinating or axonal. Microstructural alterations of the nodal region are the key to understand the pathophysiology of neuropathies with antibodies to gangliosides and the new category of nodo-paranodopathy has been proposed to better characterise these disorders and overcome some inadequacies of the dichotomous classification. Recently, the research in autoimmune neuropathies has been boosted by reports of patients carrying immunoglobulin G4 antibodies against paranodal axo-glial proteins with distinct phenotypes and showing loss of transverse bands, terminal myelin loop detachment, nodal widening and axonal loss. These patients have been classified up to now as chronic inflammatory demyelinating polyradiculoneuropathy but, in our opinion, better fit into the nodo-paranodopathy category because nerve injury is due to dismantling of the paranode, segmental de-remyelination is absent and the pathogenic mechanism is not inflammatory. Evidence from nerve conductions and electron microscopy studies in patients and mutant animal models can reconcile the apparent contrast between the electrophysiological 'demyelinating' features, explainable just by the paranodal involvement and the axonal pathology. These patients broaden the autoimmune nodo-paranodopathy category and re-emphasise the usage of the term that pointing to the site of nerve injury reminds specific pathophysiological mechanisms, reconciles contrasting electrophysiological and pathological findings, and avoids misdiagnosis and taxonomic confusion. In our opinion, the nodo-paranodopathy term more adequately classifies the peripheral nerve disorders due to an autoimmune attack directed and limited to the nodal region integrating the traditional classification of peripheral neuropathies.
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Affiliation(s)
- Antonino Uncini
- Department of Neurosciences, Imaging and Clinical Sciences University G. d'Annunzio, Chieti-Pescara, Italy
| | - Jean-Michel Vallat
- Department of Neurology and 'Centre de Référence des neuropathies rares', CHU Limoges, Limoges, France
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Restrepo-Jiménez P, Rodríguez Y, González P, Chang C, Gershwin ME, Anaya JM. The immunotherapy of Guillain-Barré syndrome. Expert Opin Biol Ther 2018; 18:619-631. [DOI: 10.1080/14712598.2018.1468885] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Affiliation(s)
- Paula Restrepo-Jiménez
- Center for Autoimmune Diseases Research (CREA), School of Medicine and Health Sciences, Universidad del Rosario, Bogotá, Colombia
| | - Yhojan Rodríguez
- Center for Autoimmune Diseases Research (CREA), School of Medicine and Health Sciences, Universidad del Rosario, Bogotá, Colombia
| | - Paulina González
- Neurology Service, Clínica Universitaria Bolivariana, Universidad Pontificia Bolivariana, Medellín, Colombia
| | - Christopher Chang
- Division of Rheumatology, Allergy and Clinical Immunology, University of California Davis, School of Medicine, Davis, CA, USA
| | - M. Eric Gershwin
- Division of Rheumatology, Allergy and Clinical Immunology, University of California Davis, School of Medicine, Davis, CA, USA
| | - Juan-Manuel Anaya
- Center for Autoimmune Diseases Research (CREA), School of Medicine and Health Sciences, Universidad del Rosario, Bogotá, Colombia
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Li P, Wang S, Zhang R, Pei J, Chen L, Cao Y, Zhang H, Yang G. Identification of CSF biomarkers by proteomics in Guillain-Barré syndrome. Exp Ther Med 2018; 15:5177-5182. [PMID: 29904402 PMCID: PMC5996704 DOI: 10.3892/etm.2018.6117] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2017] [Accepted: 06/23/2017] [Indexed: 12/20/2022] Open
Abstract
The purpose of the present study was to screen for differentially expressed proteins in the cerebrospinal fluid (CSF) of patients with Guillain-Barré syndrome (GBS). The identification of differentially expressed protein can provide new targets for understanding the pathogenic mechanism, early clinical diagnosis, prognosis and for measuring the effectiveness of interventions. We enrolled 50 GBS patients and 50 meningitis patients (control group) to compare protein expression in CSF. The GBS cases included 28 cases of acute inflammatory demyelinating polyneuropathy (AIDP) and 22 cases of acute motor axonal neuropathy (AMAN). We then performed two-dimensional differential in-gel electrophoresis combined with matrix-assisted laser desorption/ionization time-of-flight mass spectrometry to identify the differentially expressed proteins. The expression levels were validated by ELISA, and their accuracy, sensitivity, and specificity in GBS diagnosis were analyzed by the receiver operating characteristic curve. Three differentially expressed proteins were identified, including the upregulated haptoglobin (Hp) and heat shock protein 70 (Hsp70), and downregulated cystatin C. There were no significant differences between the AIDP and AMAN patients in the positive rates and quantitative expression levels of the three differentially expressed proteins. The accuracy of Hp in the diagnosis of GBS was 0.835, sensitivity was 86.7%, and specificity was 88.2%. The accuracy of cystatin C in the diagnosis of GBS was 0.827, sensitivity was 85.5%, and specificity was 89.7%. The accuracy of Hsp70 in the diagnosis of GBS was 0.841, its sensitivity was 87.8%, and its specificity was 92.3%. Hp and Hsp70 are significantly increased, and cystatin C is downregulated in CSF of GBS patients, which provides important biomarkers for early GBS diagnosis, although these proteins cannot distinguish AIDP and AMAN.
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Affiliation(s)
- Pei Li
- Department of Neurology, Tangshan Gongren Hospital, Tangshan, Hebei 063000, P.R. China
| | - Sujie Wang
- Department of Neurology, Tangshan Gongren Hospital, Tangshan, Hebei 063000, P.R. China
| | - Ruili Zhang
- Department of Neurology, Zunhua People's Hospital, Tangshan, Hebei 064200, P.R. China
| | - Jian Pei
- Department of Neurosurgery, Tangshan Gongren Hospital, Tangshan, Hebei 063000, P.R. China
| | - Lili Chen
- Department of Neurology, Tangshan Gongren Hospital, Tangshan, Hebei 063000, P.R. China
| | - Yibin Cao
- Department of Neurology, Tangshan Gongren Hospital, Tangshan, Hebei 063000, P.R. China
| | - Haoliang Zhang
- Department of Radiotherapy and Chemotherapy, Tangshan Gongren Hospital, Tangshan, Hebei 063000, P.R. China
| | - Guofeng Yang
- Department of Neurology, The Second Hospital of Hebei Medical University, Shijiazhuang, Hebei 050000, P.R. China
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Safety and efficacy of eculizumab in Guillain-Barré syndrome: a multicentre, double-blind, randomised phase 2 trial. Lancet Neurol 2018; 17:519-529. [PMID: 29685815 DOI: 10.1016/s1474-4422(18)30114-5] [Citation(s) in RCA: 78] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2017] [Revised: 02/15/2018] [Accepted: 03/15/2018] [Indexed: 01/29/2023]
Abstract
BACKGROUND Despite the introduction of plasmapheresis and immunoglobulin therapy, many patients with Guillain-Barré syndrome still have an incomplete recovery. Evidence from pathogenesis studies suggests the involvement of complement-mediated peripheral nerve damage. We aimed to investigate the safety and efficacy of eculizumab, a humanised monoclonal antibody against the complement protein C5, in patients with severe Guillain-Barré syndrome. METHODS This study was a 24 week, multicentre, double-blind, placebo-controlled, randomised phase 2 trial done at 13 hospitals in Japan. Eligible patients with Guillain-Barré syndrome were aged 18 years or older and could not walk independently (Guillain-Barré syndrome functional grade 3-5). Patients were randomly assigned (2:1) to receive 4 weeks of intravenous immunoglobulin plus either eculizumab (900 mg) or placebo; randomisation was done via a computer-generated process and web response system with minimisation for functional grade and age. The study had a parallel non-comparative single-arm outcome measure. The primary outcomes were efficacy (the proportion of patients with restored ability to walk independently [functional grade ≤2] at week 4) in the eculizumab group and safety in the full analysis set. For the efficacy endpoint, we predefined a response rate threshold of the lower 90% CI boundary exceeding 50%. This trial is registered with ClinicalTrials.gov, number, NCT02493725. FINDINGS Between Aug 10, 2015, and April 21, 2016, 34 patients were assigned to receive either eculizumab (n=23) or placebo (n=11). At week 4, the proportion of the patients able to walk independently (functional grade ≤2) was 61% (90% CI 42-78; n=14) in the eculizumab group, and 45% (20-73; n=5) in the placebo group. Adverse events occurred in all 34 patients. Three patients had serious adverse events: two in the eculizumab group (anaphylaxis in one patient and intracranial haemorrhage and abscess in another patient) and one in the placebo group (depression). The possibility that anaphylaxis and intracranial abscess were related to eculizumab could not be excluded. No deaths or meningococcal infections occurred. INTERPRETATION The primary outcome measure did not reach the predefined response rate. However, because this is a small study without statistical comparison with the placebo group, the efficacy and safety of eculizumab could be investigated in larger, randomised controlled trials. FUNDING The Japan Agency for Medical Research and Development, Ministry of Health, Labor and Welfare, and Alexion Pharmaceuticals.
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Gangliosides in Inflammation and Neurodegeneration. PROGRESS IN MOLECULAR BIOLOGY AND TRANSLATIONAL SCIENCE 2018; 156:265-287. [PMID: 29747817 DOI: 10.1016/bs.pmbts.2018.01.009] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Gangliosides play roles in the regulation of cell signaling that are mediated via membrane microdomains, lipid rafts. In this review, functions of gangliosides in the maintenance of nervous systems with a focus on regulation of inflammation and neurodegeneration are addressed. During analyses of various ganglioside-lacking mutant mice, we demonstrated that nervous tissues exhibited inflammatory reactions and subsequent neurodegeneration. Among inflammation-related genes, factors of the complement system showed up-regulation with aging. Analyses of architectures and compositions of lipid rafts in nervous tissues from these mutant mice revealed that dysfunctions of complement regulatory proteins based on disrupted lipid rafts were main factors to induce the inflammatory reactions resulting in neurodegeneration. Ganglioside changes in development and senescence, and implication of them in the integrity of cell membranes and cellular phenotypes in physiological and pathological conditions including Alzheimer disease have been summarized. Novel directions to further analyze mechanisms for ganglioside functions in membrane microdomains have been also addressed.
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Goodfellow JA, Willison HJ. Gangliosides and Autoimmune Peripheral Nerve Diseases. PROGRESS IN MOLECULAR BIOLOGY AND TRANSLATIONAL SCIENCE 2018; 156:355-382. [DOI: 10.1016/bs.pmbts.2017.12.010] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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Yamagishi Y, Suzuki H, Sonoo M, Kuwabara S, Yokota T, Nomura K, Chiba A, Kaji R, Kanda T, Kaida K, Ikeda SI, Mutoh T, Yamasaki R, Takashima H, Matsui M, Nishiyama K, Sobue G, Kusunoki S. Markers for Guillain-Barré syndrome with poor prognosis: a multi-center study. J Peripher Nerv Syst 2017; 22:433-439. [PMID: 28833828 DOI: 10.1111/jns.12234] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2017] [Revised: 08/04/2017] [Accepted: 08/07/2017] [Indexed: 12/17/2022]
Abstract
Guillain-Barré syndrome (GBS) is an acute monophasic neuropathy. Prognostic tools include the modified Erasmus GBS outcome score (mEGOS), Erasmus GBS respiratory insufficiency score (EGRIS), and the increase in serum IgG levels (ΔIgG) 2 weeks after intravenous immunoglobulin (IVIg) treatment. Given that proportions of GBS subtypes differ between Western countries and Japan, the usefulness of these tools in Japan or other countries remains unknown. We enrolled 177 Japanese patients with GBS from 15 university hospitals and retrospectively obtained mEGOS and EGRIS for all and ΔIgG status for 79 of them. High mEGOS scores on admission or on day 7 were significantly associated with poorer outcomes (unable to walk independently at 6 months). High EGRIS scores (≥5 points) were associated with an increased risk for mechanical ventilation. Patients with ΔIgG <1,108 mg/dl had significantly poorer outcomes. We suggest that mEGOS, EGRIS, and ΔIgG in GBS are clinically relevant in Japan.
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Affiliation(s)
- Yuko Yamagishi
- Department of Neurology, Kindai University, Faculty of Medicine, Osaka-sayama, Japan
| | - Hidekazu Suzuki
- Department of Neurology, Kindai University, Faculty of Medicine, Osaka-sayama, Japan
| | - Masahiro Sonoo
- Department of Neurology, Teikyo University School of Medicine, Tokyo, Japan
| | - Satoshi Kuwabara
- Department of Neurology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Takanori Yokota
- Department of Neurology, Tokyo Medical and Dental University, Faculty of Medicine, Tokyo, Japan
| | - Kyoichi Nomura
- Department of Neurology, Saitama Medical Center, Saitama Medical University, Faculty of Medicine, Kawagoe, Japan
| | - Atsuro Chiba
- Department of Neurology, Kyorin University, Faculty of Medicine, Mitaka, Japan
| | - Ryuji Kaji
- Department of Neurology, Tokushima University, Faculty of Medicine, Tokushima, Japan
| | - Takashi Kanda
- Department of Neurology, Yamaguchi University, Faculty of Medicine, Ube, Japan
| | - Kenichi Kaida
- Department of Neurology, National Defense Medical College, Tokorozawa, Japan
| | - Shu-Ichi Ikeda
- Department of Neurology, Shinshu University, Faculty of Medicine, Matsumoto, Japan
| | - Tatsuro Mutoh
- Department of Neurology, Fujita Health University School of Medicine, Faculty of Medicine, Toyoake, Japan
| | - Ryo Yamasaki
- Department of Neurology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Hiroshi Takashima
- Department of Neurology, Kagoshima University, Faculty of Medicine, Kagoshima, Japan
| | - Makoto Matsui
- Department of Neurology, Kanazawa Medical University, Kahoku, Japan
| | - Kazutoshi Nishiyama
- Department of Neurology, Kitazato University, Faculty of Medicine, Sagamihara, Japan
| | - Gen Sobue
- Department of Neurology, Nagoya University, Graduate School of Medicine, Nagoya, Japan
| | - Susumu Kusunoki
- Department of Neurology, Kindai University, Faculty of Medicine, Osaka-sayama, Japan
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