Guillain-Barré syndrome and Campylobacter jejuni: a serological study

Axonal pathology in early stages of Guillain-Barré syndrome

INTRODUCTION

Guillain-Barré syndrome (GBS) is an acute-onset, immune-mediated disease of the peripheral nervous system. It may be classified into 2 main subtypes: demyelinating (AIDP) and axonal (AMAN). This study aims to analyse the mechanisms of axonal damage in the early stages of GBS (within 10 days of onset).

DEVELOPMENT

We analysed histological, electrophysiological, and imaging findings from patients with AIDP and AMAN, and compared them to those of an animal model of myelin P2 protein-induced experimental allergic neuritis. Inflammatory oedema of the spinal nerve roots and spinal nerves is the initial lesion in GBS. The spinal nerves of patients with fatal AIDP may show ischaemic lesions in the endoneurium, which suggests that endoneurial inflammation may increase endoneurial fluid pressure, reducing transperineurial blood flow, potentially leading to conduction failure and eventually to axonal degeneration. In patients with AMAN associated with anti-ganglioside antibodies, nerve conduction block secondary to nodal sodium channel dysfunction may affect the proximal, intermediate, and distal nerve trunks. In addition to the mechanisms involved in AIDP, active axonal degeneration in AMAN may be associated with nodal axolemma disruption caused by anti-ganglioside antibodies.

CONCLUSION

Inflammatory oedema of the proximal nerve trunks can be observed in early stages of GBS, and it may cause nerve conduction failure and active axonal degeneration.

Axonal pathology in early stages of Guillain-Barré syndrome

INTRODUCTION

Guillain-Barré syndrome (GBS) is an acute-onset, immune-mediated disease of the peripheral nervous system. It may be classified into 2 main subtypes: demyelinating (AIDP) and axonal (AMAN). This study aims to analyse the mechanisms of axonal damage in the early stages of GBS (within 10days of onset).

DEVELOPMENT

We analysed histological, electrophysiological, and imaging findings from patients with AIDP and AMAN, and compared them to those of an animal model of myelin P2 protein-induced experimental allergic neuritis. Inflammatory oedema of the spinal nerve roots and spinal nerves is the initial lesion in GBS. The spinal nerves of patients with fatal AIDP may show ischaemic lesions in the endoneurium, which suggests that endoneurial inflammation may increase endoneurial fluid pressure, reducing transperineurial blood flow, potentially leading to conduction failure and eventually to axonal degeneration. In patients with AMAN associated with anti-ganglioside antibodies, nerve conduction block secondary to nodal sodium channel dysfunction may affect the proximal, intermediate, and distal nerve trunks. In addition to the mechanisms involved in AIDP, active axonal degeneration in AMAN may be associated with nodal axolemma disruption caused by anti-ganglioside antibodies.

CONCLUSION

Inflammatory oedema of the proximal nerve trunks can be observed in early stages of GBS, and it may cause nerve conduction failure and active axonal degeneration.

Gut Microbiota and Autoimmune Diseases: A Charming Real World Together with Probiotics

BACKGROUND

The role of gut microbiota in human disease is fascinating for hundreds of researchers worldwide. Many works have highlighted that gut microbiota modulates the immune system and that its disruption can trigger autoimmune and inflammatory immune-mediated diseases. Probiotics are able to positively modify microbiota composition.

OBJECTIVE

The aim of this review is to report the most important findings regarding the effects of probiotics administration in the most common autoimmune disease and inflammatory immune-mediated diseases.

METHODS

Literature research was performed in PubMed, Google Scholar, and Medline, as well as in specific journal websites using the keywords: "autoimmunity", "microbiota", and "probiotics". The article selection has been made independently by three authors, and controversies have been solved by a fourth researcher. Only English-language articles were included and preference was given to clinical trials, meta-analysis, and case series. After the review process, 68 articles have been considered.

RESULTS

Relying on this evidence, many studies have investigated the potential of probiotics in restoring gut eubiosis, thus affecting pathogenesis, clinical manifestations, and course of these pathologies. Even in the light of few and sometimes contradictory studies, physicians should start to consider these preliminary findings when approaching patients suffering from autoimmune disease. After an accurate case-by-case evaluation of potential candidates, probiotics might be introduced besides the standard therapeutic plan as supportive measures.

Spinal fluid IgG antibodies from patients with demyelinating diseases bind multiple sclerosis-associated bacteria

Abstract

A panel of 10 IgG enzyme-linked immunosorbent assays (ELISAs) were developed for the detection of anti-microbial immune responses in the cerebrospinal fluid (CSF) of patients with demyelinating diseases (DD). The anti-microbial ELISA assays follow on prior human brain tissue RNA sequencing studies that established multiple sclerosis (MS) microbial candidates. Lysates included in the ELISA panel were derived from Akkermansia muciniphila, Atopobium vaginae, Bacteroides fragilis, Lactobacillus paracasei, Odoribacter splanchnicus, Pseudomonas aeruginosa, Cutibacterium (Propionibacterium) acnes, Fusobacterium necrophorum, Porphyromonas gingivalis, and Streptococcus mutans. CSF responses from patients with demyelinating diseases (DD, N = 14) were compared to those with other neurological diseases (OND, N = 8) and controls (N = 13). Commercial positive and negative control CSF specimens were run with each assay. ELISA index values were derived for each specimen against each of the 10 bacterial lysates. CSF reactivity was significantly higher in the DD group compared to the controls against Akkermansia, Atopobium, Bacteroides, Lactobacillus, Odoribacter, and Fusobacterium. Four of the 11 tested DD group subjects had elevated antibody indexes against at least one of the 10 bacterial species, suggesting intrathecal antibody production. This CSF serological study supports the hypothesis that several of the previously identified MS candidate microbes contribute to demyelination in some patients.

Key messages

A panel of 10 IgG enzyme-linked immunosorbent assays (ELISAs) were developed for the detection of anti-microbial immune responses in the cerebrospinal fluid (CSF) of patients with demyelinating diseases, including multiple sclerosis and acute disseminated encephalomyelitis.

CSF reactivity was significantly higher in the demyelination group compared to the controls against the bacteria Akkermansia, Atopobium, Bacteroides, Lactobacillus, Odoribacter, and Fusobacterium.

Several of the demyelination subjects had elevated antibody indexes against at least one of the 10 antigens, suggesting at least limited intrathecal production of anti-bacterial antibodies.

This CSF serological study supports the hypothesis that several of the previously identified MS candidate microbes contribute to demyelination in some patients.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00109-021-02085-z.

Clinical Evidence for the Microbiome in Inflammatory Diseases

Clinical evidence is accumulating for a role of the microbiome in contributing to or modulating severity of inflammatory diseases. These studies can be organized by various organ systems involved, as well as type of study approach utilized, whether investigators compared the microbiome of cases versus controls, followed patients longitudinally, or intervened with antibiotics, prebiotics, or bacterial introduction. In this review, we summarize the clinical evidence supporting the microbiome as an important mechanism in the onset and maintenance of inflammation.

Suspect Guillain-Barré syndrome in a male rhesus macaque (Macaca mulatta)

Guillain-Barré syndrome (GBS) is a rare, mainly acute inflammatory polyneuropathy in humans. It is frequently post-infectious with auto antibodies being formed against myelin sheaths, resulting in a progressive and more-or-less severe paralysis of the motor neuron and cranial nerves. Mortality is low and 60 % of the patients recover completely from the disease after intensive treatment. In animals, there are a few diseases that closely resemble GBS, but cases of GBS in monkeys seem to be scarce. In this case report, the clinical course of a progressive tetraplegia in a male rhesus macaque is described. Clinical, cerebrospinal fluid (CSF), electroneurography (ENG) and electromyography (EMG), and pathological findings revealed symptoms very similar to human GBS.

Guillain-Barré syndrome: a century of progress

In 1916, Guillain, Barré and Strohl reported on two cases of acute flaccid paralysis with high cerebrospinal fluid protein levels and normal cell counts - novel findings that identified the disease we now know as Guillain-Barré syndrome (GBS). 100 years on, we have made great progress with the clinical and pathological characterization of GBS. Early clinicopathological and animal studies indicated that GBS was an immune-mediated demyelinating disorder, and that severe GBS could result in secondary axonal injury; the current treatments of plasma exchange and intravenous immunoglobulin, which were developed in the 1980s, are based on this premise. Subsequent work has, however, shown that primary axonal injury can be the underlying disease. The association of Campylobacter jejuni strains has led to confirmation that anti-ganglioside antibodies are pathogenic and that axonal GBS involves an antibody and complement-mediated disruption of nodes of Ranvier, neuromuscular junctions and other neuronal and glial membranes. Now, ongoing clinical trials of the complement inhibitor eculizumab are the first targeted immunotherapy in GBS.

Antibody cross-reactivities between gangliosides and lipopolysaccharides of Campylobacter jejuni serotypes associated with Guillain-Barré syndrome

Ganglioside-antibodies produced subsequent to Campylobacter jejuni infection may play a role in the pathogenesis of the neurological disorder Guillain-Barré syndrome (GBS). Since lipopolysaccharides (LPS) of certain C. jejuni serotypes associated with GBS (O:2, O:4, O:19) exhibit structural mimicry of gangliosides in their core oligosaccharides, we investigated antibody and ligand cross-reactivities between gangliosides and LPS of these C. jejuni serotypes. GM1-antibody reacted with O:19 LPS reflecting GM1 mimicry by the O:19 core oligosaccharide. On the other hand, asialoGM1-antibody bound to O:2 and O:19 LPS indicating a shared epitope not dependent on ganglioside mimicry. Serum IgA from GBS patients after C. jejuni infection reacted with gangliosides, predominantly GM1, and LPS of all three serotypes. Cholera toxin (GM1 ligand) recognized O:4 and O:19 LPS, whereas peanut agglutinin (Galβ1-3GalNAc ligand) recognized LPS of all three serotypes, thereby confirming structural mimicry. These results suggest that LPS from certain C. jejuni strains may function as cross-reactive antigens for anti-ganglioside B cells.

Unexpected Rapid Improvement and Neurogenic Stunned Myocardium in a Patient With Acute Motor Axonal Neuropathy: A Case Report and Literature Review

Acute Motor Axonal Neuropathy-type Guillain-Barré Syndrome (GBS) is a subset of GBS with either a rapidly improving or protracted course that was first described in China. We describe a 27-year-old previously healthy woman with weakness that progressed to complete tetraplegia and areflexia within 2 weeks after an upper respiratory illness. A lumbar puncture performed 4 days after onset of neurologic symptoms was inconclusive for GBS, and electromyography revealed complete motor axonal neuropathy. The patient had Mycoplasma pneumoniae in her nares and blood, and several antiganglioside antibodies in her blood. She was treated with plasmapheresis, antibiotics, and physical therapy. Her motor function and reflexes improved rapidly with treatment, and she was able to ambulate within 3 weeks. She also experienced cardiomyopathy, which improved with plasmapheresis. We report a rare case of Mycoplasma pneumonia-associated acute motor axonal neuropathy-type GBS presenting with complete tetraplegia, areflexia, and neurogenic stunned myocardium that rapidly improved with plasmapheresis.

Chicken, beams, and Campylobacter: rapid differentiation of foodborne bacteria via vibrational spectroscopy and MALDI-mass spectrometry

Campylobacter species are one of the main causes of food poisoning worldwide. Despite the availability of established culturing and molecular techniques, due to the fastidious nature of these microorganisms, simultaneous detection and species differentiation still remains challenging. This study focused on the differentiation of eleven Campylobacter strains from six species, using Fourier transform infrared (FT-IR) and Raman spectroscopies, together with matrix-assisted laser desorption ionisation-time of flight-mass spectrometry (MALDI-TOF-MS), as physicochemical approaches for generating biochemical fingerprints. Cluster analysis of data from each of the three analytical approaches provided clear differentiation of each Campylobacter species, which was generally in agreement with a phylogenetic tree based on 16S rRNA gene sequences. Notably, although C. fetus subspecies fetus and venerealis are phylogenetically very closely related, using FT-IR and MALDI-TOF-MS data these subspecies were readily differentiated based on differences in the lipid (2920 and 2851 cm(-1)) and fingerprint regions (1500-500 cm(-1)) of the FT-IR spectra, and the 500-2000 m/z region of the MALDI-TOF-MS data. A finding that was further investigated with targeted lipidomics using liquid chromatography-mass spectrometry (LC-MS). Our results demonstrate that such metabolomics approaches combined with molecular biology techniques may provide critical information and knowledge related to the risk factors, virulence, and understanding of the distribution and transmission routes associated with different strains of foodborne Campylobacter spp.

Rapid and reversible responses to IVIG in autoimmune neuromuscular diseases suggest mechanisms of action involving competition with functionally important autoantibodies

Intravenous immunoglobulin (IVIG) is widely used in autoimmune neuromuscular diseases whose pathogenesis is undefined. Many different effects of IVIG have been demonstrated in vitro, but few studies actually identify the mechanism(s) most important in vivo. Doses and treatment intervals are generally chosen empirically. Recent studies in Guillain-Barré syndrome and chronic inflammatory demyelinating polyneuropathy show that some effects of IVIG are readily reversible and highly dependent on the serum IgG level. This suggests that in some autoantibody-mediated neuromuscular diseases, IVIG directly competes with autoantibodies that reversibly interfere with nerve conduction. Mechanisms of action of IVIG which most likely involve direct competition with autoantibodies include: neutralization of autoantibodies by anti-idiotypes, inhibition of complement deposition, and increasing catabolism of pathologic antibodies by saturating FcRn. Indirect immunomodulatory effects are not as likely to involve competition and may not have the same reversibility and dose-dependency. Pharmacodynamic analyses should be informative regarding most relevant mechanism(s) of action of IVIG as well as the role of autoantibodies in the immunopathogenesis of each disease. Better understanding of the role of autoantibodies and of the target(s) of IVIG could lead to more efficient use of this therapy and better patient outcomes.

Bilateral Ankle and Subtalar Joint Fusion Secondary to Guillain Barré-Induced Foot Drop

Guillain-Barré syndrome is a serious disorder that occurs when the body's immune system mistakenly attacks the peripheral nervous system. This leads to nerve inflammation and damage that can cause muscle weakness and/or paralysis, including foot drop. Therapy ranges from supportive measures, such as physical therapy, to surgical intervention. It appears from the published data that these patients, generally, have been left to their own devices, because no known cure is available, necessitating reliance on others for their daily activities and ambulation. We present a unique surgical option, with a follow-up period of 24 months, in which bilateral subtalar and ankle fusion allowed unassisted ambulation to a patient who might otherwise have never walked again.

Glycoconjugates as target antigens in peripheral neuropathies

Identification and characterization of antigens present at the human peripheral nerve is a great challenge in the field of neuroimmunology. The latest investigations are focused on the understanding of the biology of glycoconjugates present at the peripheral nerve, and their immunological reactivity. Increased titers of antibodies that recognize carbohydrate determinants of glycoconjugates (glycolipids and glycoproteins) are associated with distinct neuropathic syndromes. There is considerable cross-reactivity among anti-ganglioside antibodies, resulting from shared oligosaccharide epitopes, possibly explaining the overlap in syndromes observed in many affected patients. Sera from patients with neuropathies (GBS, chronic inflammatory demielynating polyneuropathy - CIDP, multifocal motor neuropathy - MMN), cross-react with glycoproteins isolated from human peripheral nerve and from Campylobacter jejuni O:19. The frequency of occurrence of antibodies against these glycoproteins is different, depending of the type of neuropathy. Identification of the cross-reactive glycoproteins and possible additional auto antigens could be useful in laboratory evaluation of peripheral neuropathies and help to develop a more effective therapeutic approach.

Specificity of a UDP-GalNAc pyranose-furanose mutase: a potential therapeutic target for Campylobacter jejuni infections

Pyranose-furanose mutases are essential enzymes in the life cycle of a number of microorganisms, but are absent in mammalian systems, and hence represent novel targets for drug development. To date, all such mutases show preferential recognition of a single substrate (e.g., UDP-Gal). We report here the detailed structural characterization of the first bifunctional pyranose-furanose mutase, which recognizes both UDP-Gal and UDP-GalNAc. The enzyme under investigation (cjUNGM) is involved in the biosynthesis of capsular polysaccharides (CPSs) in Campylobacter jejuni 11168. These CPSs are known virulence factors that are required for adhesion and invasion of human epithelial cells. Using a combination of UV/visible spectroscopy, X-ray crystallography, saturation transfer difference NMR spectroscopy, molecular dynamics and CORCEMA-ST calculations, we have characterized the binding of the enzyme to both UDP-Galp and UDP-GalpNAc, and compared these interactions with those of a homologous monofunctional mutase enzyme from E. coli (ecUGM). These studies reveal that two arginines in cjUNGM, Arg59 and Arg168, play critical roles in the catalytic mechanism of the enzyme and in controlling its specificity to ultimately lead to a GalfNAc-containing CPS. In ecUGM, these arginines are replaced with histidine and lysine, respectively, and this results in an enzyme that is selective for UDP-Gal. We propose that these changes in amino acids allow C. jejuni 11168 to produce suitable quantities of the sugar nucleotide substrate required for the assembly of a CPS containing GalfNAc, which is essential for viability.

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

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

Review of current methodologies to isolate and identify Campylobacter spp. from foods

This article summarizes the most effective protocols to isolate Campylobacter spp. (mainly Campylobacter jejuni and Campylobacter coli) from food, primarily poultry products, and includes a summary of the current methods recommended by the Food and Drug Administration and the U.S. Department of Agriculture in the USA, and ISO in Europe. The recommended temperature for incubation of the samples throughout the isolation procedure is 42°C. The enrichment of the samples for 48h, which can be performed under aerobic conditions, is recommended to achieve a detectable number of Campylobacter cells. Bolton broth or buffered peptone water supplemented with cefoperazone and amphotericin B is commonly used enrichment broths. The transfer of the enriched samples to plate media using membrane filters helps to obtain pure Campylobacter colonies. Charcoal cefoperazone deoxycholate (CCDA) is the best choice among all plate media. There is no need to add oxygen quenching substances or blood to enrichment broth for the isolation of Campylobacter spp. However, the addition of blood to plate media aids in differential identification of presumptive colonies. Phase contrast microscopy and latex agglutination tests are confirmatory tests for presumptive Campylobacter isolates. The use of multiplex polymerase chain reaction (mPCR) assays is the simplest and most rapid method to identify isolates to the species level. mPCR assays, or other methods assessing DNA sequence variations, will probably become the confirmation procedure of choice in the future. Recent work with retail broiler meat has revealed that the rinsing of meat is more sensitive for the recovery of naturally contaminated retail broiler meat than current reference methods and requires less time for preparation and processing of the samples. This protocol could be coupled with DNA-based methods for a fast screening of positive samples.

Antibody testing in peripheral nerve disorders

The identification of autoantibodies associated with dysimmune neuropathies was a major contribution to the characterization of peripheral nerve disorders, the understanding of their pathophysiology, and the clinical diagnosis of neuropathies. Antibodies directed to GM1, GQ1b, and disyalilated gangliosides, and anti-MAG antibodies are very useful in the diagnosis of acute or chronic motor or sensory-motor neuropathies with or without monoclonal IgM. Anti-onconeural anti-Hu and anti-CV2/CRMP antibodies allow when they are detected the diagnosis of paraneoplastic neuropathies. This chapter focuses on the description of these antibodies as diagnostic markers and on their immunopathogenesis. We give a background overview on the origin of these antibodies, their detection, and review those studies, which clearly show that these antibodies are capable of binding to the target tissues in peripheral nerve and thereby can exert a variety of pathophysiological effects. The corresponding electrophysiological and histological changes observed both in human and animal models are exemplified in order to get a better understanding of the immune mechanisms of these antibody-mediated neuropathies.

Guillain-Barré syndrome and anti-ganglioside antibodies: a clinician-scientist's journey

Guillain-Barré syndrome (GBS) is the most frequent cause of acute flaccid paralysis. Having seen my first GBS patient in 1989, I have since then dedicated my time in research towards understanding the pathogenesis of GBS. Along with several colleagues, we identified IgG autoantibodies against ganglioside GM1 in two patients with GBS subsequent to Campylobacter jejuni enteritis. We proceeded to demonstrate molecular mimicry between GM1 and bacterial lipo-oligosaccharide of C. jejuni isolated from a patient with GBS. Our group then established a disease model for GBS by sensitization with GM1 or GM1-like lipo-oligosaccharide. With this, a new paradigm that carbohydrate mimicry can cause autoimmune disorders was demonstrated, making GBS the first proof of molecular mimicry in autoimmune disease. Patients with Fisher syndrome, characterized by ophthalmoplegia and ataxia, can develop the disease after an infection by C. jejuni. We showed that the genetic polymorphism of C. jejuni sialyltransferase, an enzyme essential to the biosynthesis of ganglioside-like lipo-oligosaccharides determines whether patients develop GBS or Fisher syndrome. This introduces another paradigm that microbial genetic polymorphism can determine the clinical phenotype of human autoimmune diseases. Similarities between the clinical presentation of Fisher syndrome and Bickerstaff brainstem encephalitis have caused debate as to whether they are in fact the same disease. We demonstrated that IgG anti-GQ1b antibodies were common to both, suggesting that they are part of the same disease spectrum. We followed this work by clarifying the nosological relationship between the various clinical presentations within the anti-GQ1b antibody syndrome. In this review, I wanted to share my journey from being a clinician to a clinician-scientist in the hopes of inspiring younger clinicians to follow a similar path.

Immunopathology and Th1/Th2 immune response of Campylobacter jejuni-induced paralysis resembling Guillain-Barré syndrome in chicken

Immunopathogenesis of Campylobacter jejuni-associated Guillain-Barré syndrome (GBS) is not yet well established probably due to lack of experimental model. Therefore, we studied the Th1/Th2 immune response and pathological changes in C. jejuni-induced chicken model for GBS. C. jejuni (5 × 10(9) CFU/ml) and placebo were fed to 30 chickens each. Stools of all birds were negative for C. jejuni by culture and PCR before experiment. The birds were regularly assessed for disease symptoms up to 30 days. Sciatic nerves from all chickens were examined at 5 days intervals by histopathology and immunohistochemistry, and also for the expression of Th1/Th2 cytokines. Twenty-two chickens (73.3%) developed diarrhea after C. jejuni infection; 18 (60.0%) experimental chickens developed GBS-like paralytic neuropathy. Pathology in the sciatic nerves of these chickens included perinodal and/or patchy demyelination, perivascular focal lymphocytic infiltration, myelin swelling and presence of macrophages within the nerve fibers on 10th-20th post-infection day (PID). Cytokines (IFN-γ, IL-1β, TNF-α, IL-6 and IL-2) were elevated in early phase (5th-15th PID) and TGF-β2, IL-10 and IL-4 in the recovery phase (25th-30th PID) of the disease. The study provides evidence that C. jejuni infection in the chicken can provide an experimental animal model of GBS.

Long-term health risks for children and young adults after infective gastroenteritis

To quantify the risk and types of sequelae attributable to prior enteric infections, we undertook a population-based retrospective cohort study using linked administrative records. The risk for first-time hospitalization for sequelae was modeled by using Cox proportional regression analysis controlling for other health and sociodemographic factors. We identified a significant increase of 64% in the rate of first-time hospitalization for sequelae for persons with prior enteric infections: 52% for intragastrointestinal sequelae and 63% for extragastrointestinal sequelae compared with first-time hospitalization for those without prior infection. Extragastrointestinal sequelae occurred predominantly during the first 5 years after first-time enteric infection. In contrast, most intragastrointestinal sequelae occurred >10 years later. Infective gastroenteritis during childhood or adolescence increases the risk for first-time hospitalization for intragastrointestinal and extragastrointestinal disease over the 2 decades after first-time enteric infection, highlighting the importance of identifying ways of reducing the incidence of such infections.

Quantifying the association between Campylobacter infection and Guillain-Barré syndrome: a systematic review

Guillain-Barré Syndrome (GBS) is a neurologic disease that causes ascending paralysis and is triggered by a preceding bacterial or viral infection. Several studies have shown that patients with GBS have a recent history of infection due to Campylobacter jejuni. A literature review of published studies that reported rates of Campylobacter infection before or in conjunction with GBS was done. These reported data were used for calculating the proportion of GBS cases who tested positive for Campylobacter compared to the control population and the incidence of GBS among patients infected with Campylobacter. Results of the analysis suggest that 31% of 2,502 GBS cases included in these papers are attributable to Campylobacter infection.

Clinical and electrophysiological features of the 2007 Guillain-Barré syndrome epidemic in northeast China

Guillain-Barré syndrome (GBS) generally presents sporadically. Epidemics of GBS are unusual. We reviewed the medical records of 26 patients hospitalized for GBS during the 2007 GBS epidemic in northeast China. The objective was to determine whether there were clinical and electrophysiological characteristics. All patients had drunk unboiled water, and the illness was preceded by diarrhea in 19 (73%) patients. Only 1 patient had a Campylobacter jejuni infection, whereas 14 (54%) patients exhibited features of acute motor axonal neuropathy (AMAN). The most common electrophysiological findings in early GBS included decreased compound muscle action potential (CMAP) amplitude (62%), abnormal F waves (73%), and abnormal H reflexes (62%). This epidemic of GBS appears to have been associated with consumption of contaminated water. The main subtype was AMAN, which was associated with a longer duration of illness and a worse prognosis. Electrodiagnostic evaluations are helpful for diagnosis in the primary stages of GBS.

Characteristics of lipo-oligosaccharide loci of Campylobacter jejuni isolates associated with Guillain-Barré Syndrome from Hebei, China

Ganglioside mimicry by C.jejuni lipo-oligosaccharides (LOS) could induce the production of autoantibodies against gangliosides and the development of Guillain-Barré syndrome (GBS). The LOS biosynthesis region exhibits significant variation with different strains. Using PCR amplifications of genes from published LOS loci and sequencing the LOS biosynthesis loci, the eight GBS-associated C. jejuni strains from HeBei could be classified into four classes. The expression of sialylated LOS structures (class A) or non-sialylated LOS structures(class F, H and P) in the C. jejuni LOS is considered to be two different factors for the induction of GBS.

Characterization of a bifunctional pyranose-furanose mutase from Campylobacter jejuni 11168

UDP-galactopyranose mutases (UGM) are the enzymes responsible for the synthesis of UDP-galactofuranose (UDP-Galf) from UDP-galactopyranose (UDP-Galp). The enzyme, encoded by the glf gene, is present in bacteria, parasites, and fungi that express Galf in their glycoconjugates. Recently, a UGM homologue encoded by the cj1439 gene has been identified in Campylobacter jejuni 11168, an organism possessing no Galf-containing glycoconjugates. However, the capsular polysaccharide from this strain contains a 2-acetamido-2-deoxy-d-galactofuranose (GalfNAc) moiety. Using an in vitro high performance liquid chromatography assay and complementation studies, we characterized the activity of this UGM homologue. The enzyme, which we have renamed UDP-N-acetylgalactopyranose mutase (UNGM), has relaxed specificity and can use either UDP-Gal or UDP-GalNAc as a substrate. Complementation studies of mutase knock-outs in C. jejuni 11168 and Escherichia coli W3110, the latter containing Galf residues in its lipopolysaccharide, demonstrated that the enzyme recognizes both UDP-Gal and UDP-GalNAc in vivo. A homology model of UNGM and site-directed mutagenesis led to the identification of two active site amino acid residues involved in the recognition of the UDP-GalNAc substrate. The specificity of UNGM was characterized using a two-substrate co-incubation assay, which demonstrated, surprisingly, that UDP-Gal is a better substrate than UDP-GalNAc.

Association of Campylobacter jejuni infection with childhood Guillain-Barré syndrome: a case-control study

A prospective case-control study was conducted to determine the association between Campylobacter jejuni infection and childhood Guillain-Barré syndrome in the Indian population. We found evidence of recent Campylobacter jejuni infection in 27.7% of patients with Guillain-Barré syndrome, as compared with 2.3% in neurological controls (P = .003) and 2.3% in nonneurological controls (P = .003). Of the 15 patients with Campylobacter jejuni infection, 8 (53.3%) reported having had diarrhea within 12 weeks before the onset of the neurologic illness. Our results suggest association between recent Campylobacter jejuni infection and bulbar weakness (P = .043). No statistical difference was observed between the Campylobacter jejuni positive and negative groups with respect to age, other clinical features, albuminocytological dissociation, and residual paralysis at follow-up. It is concluded that subclinical Campylobacter jejuni infection is an important antecedent illness in childhood Guillain-Barré syndrome in the Indian population.

Peripheral neuropathy

Patients presenting with symptoms of peripheral neuropathy are commonplace in the practice of generalist physicians, office based or hospitalists. Although there are at least a thousand different causes for peripheral neuropathy, the majority of patients can be properly diagnosed (and managed) based on framing the diagnostic possibilities within one of six typical scenarios. The case presentations in this article illustrate common and less common but essential presentations and the approach to evaluation and treatment. For these patients the key to success lies in the history and clinical examination findings.

Influenza, Campylobacter and Mycoplasma infections, and hospital admissions for Guillain-Barré syndrome, England

TOC Summary line: Campylobacter, Mycoplasma pneumoniae, and influenza (or influenza vaccination) act as infectious triggers for Guillain-Barré syndrome.

Guillain-Barré syndrome (GBS) is the most common cause of acute flaccid paralysis in polio-free regions. Considerable evidence links Campylobacter infection with GBS, but evidence that implicates other pathogens as triggers remains scarce. We conducted a time-series analysis to investigate short-term correlations between weekly laboratory-confirmed reports of putative triggering pathogens and weekly hospitalizations for GBS in England from 1993 through 2002. We found a positive association between the numbers of reports of laboratory-confirmed influenza A in any given week and GBS hospitalizations in the same week. Different pathogens may trigger GBS in persons of different ages; among those <35 years, numbers of weekly GBS hospitalizations were associated with weekly Campylobacter and Mycoplasma pneumoniae reports, whereas among those >35 years, positive associations were with influenza. Further studies should estimate the relative contribution of different pathogens to GBS incidence, overall and by age group, and determine whether influenza is a real trigger for GBS or a marker for influenza vaccination.

Guillain-Barré syndrome and preceding infection with campylobacter, influenza and Epstein-Barr virus in the general practice research database

Background

A number of infectious agents have previously been suggested as risk factors for the development of Guillain-Barré syndrome (GBS), but robust epidemiologic evidence for these associations is lacking.

Methods and Findings

We conducted a nested case-control study using data from the United Kingdom General Practice Research Database between 1991 and 2001. Controls were matched to cases on general practice clinic, sex, year of birth and date of outcome diagnosis in their matched case. We found positive associations between GBS and infection with Campylobacter, Epstein-Barr virus and influenza-like illness in the previous two months, as well as evidence of a protective effect of influenza vaccination. After correction for under-ascertainment of Campylobacter infection, the excess risk of GBS following Campylobacter enteritis was 60-fold and 20% of GBS cases were attributable to this pathogen.

Conclusions

Our findings indicate a far greater excess risk of GBS among Campylobacter enteritis patients than previously reported by retrospective serological studies. In addition, they confirm previously suggested associations between infection due to Epstein-Barr virus infection and influenza-like illness and GBS. Finally, we report evidence of a protective effect of influenza vaccination on GBS risk, which may be mediated through protection against influenza disease, or result from a lower likelihood of vaccination among those with recent infection. Cohort studies of GBS incidence in this population would help to clarify the burden of GBS due to influenza, and any potential protective effect of influenza vaccination.

Campylobacter jejuni strains compete for colonization in broiler chicks

Campylobacter jejuni isolates possess multiple adhesive proteins termed adhesins, which promote the organism's attachment to epithelial cells. Based on the proposal that one or more adhesins are shared among C. jejuni isolates, we hypothesized that C. jejuni strains would compete for intestinal and cecal colonization in broiler chicks. To test this hypothesis, we selected two C. jejuni strains with unique SmaI pulsed-field gel electrophoresis macrorestriction profiles and generated one nalidixic acid-resistant strain (the F38011 Nal(r) strain) and one streptomycin-resistant strain (the 02-833L Str(r) strain). In vitro binding assays revealed that the C. jejuni F38011 Nal(r) and 02-833L Str(r) strains adhered to LMH chicken hepatocellular carcinoma epithelial cells and that neither strain influenced the binding potential of the other strain at low inoculation doses. However, an increase in the dose of the C. jejuni 02-833L Str(r) strain relative to that of the C. jejuni F38011 Nal(r) strain competitively inhibited the binding of the C. jejuni F38011 Nal(r) strain to LMH cells in a dose-dependent fashion. Similarly, the C. jejuni 02-833L Str(r) strain was found to significantly reduce the efficiency of intestinal and cecal colonization by the C. jejuni F38011 Nal(r) strain in broiler chickens. Based on the number of bacteria recovered from the ceca, the maximum number of bacteria that can colonize the digestive tracts of chickens may be limited by host constraints. Collectively, these data support the hypothesis that C. jejuni strains compete for colonization in chicks and suggest that it may be possible to design novel intervention strategies for reducing the level at which C. jejuni colonizes the cecum.

Ganglioside mimicry and peripheral nerve disease

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

Utility of serum Campylobacter specific antibodies in determining prior Campylobacter infection in neurological disease

Campylobacter jejuni has been implicated in the pathogenesis of Guillain-Barre syndrome (GBS); however, little information exists on the utility of Campylobacter serology in determining recent infection in the patient population. C. jejuni specific antibodies (CAs) were measured in 420 blood donors (controls), 99 patients with recent C. jejuni infection, 34 patients with central nervous system disorders (neurology controls), and 44 patients with peripheral nervous system (PNS) disorders: 18 with GBS, 12 with MND and 14 with chronic inflammatory neuropathies. Elevated CA titres consistent with recent C. jejuni infection were found in six of the 44 patients with PNS disorders (three with GBS, two with neuropathy, and one with MND, only one of whom had a history of recent C. jejuni infection), compared with two of 454 controls (p = 0.00001). Therefore, we conclude that CAs are often raised in patients with PNS disorders who do not have a history of recent C. jejuni gastroenteritis, so Campylobacter serology may be an unreliable marker of recent infection in this patient group.

Improved serological diagnosis stresses the major role of Campylobacter jejuni in triggering Guillain-Barré syndrome

Guillain-Barré syndrome (GBS) is a postinfectious autoimmune polyradiculoneuropathy. The most frequent antecedent pathogen is Campylobacter jejuni, followed by cytomegalovirus. However, more than 40% of GBS cases currently cannot be attributed to triggering events. This might be due to the shortcomings of the serological assays used for diagnosing infections, in particular for C. jejuni. In our study investigating 36 patients with acute GBS, standard serological methods identified the triggering viral or bacterial etiology in only 25% of cases. However, using a highly specific enzyme-linked immunosorbent assay based on two recombinant outer antigens encoded by C. jejuni genes Cj0017 (P39) and Cj0113 (P18), we found serological evidence of a preceding C. jejuni infection in 80.6% of the patients but in only 3.5% of the controls. We conclude that the role of C. jejuni in triggering GBS has been greatly underestimated.

Infectious diarrhea in developed and developing countries

Diarrhea from gastrointestinal infection remains a common problem. In industrialized countries, management is aimed at reducing morbidity and defining groups that may benefit from further investigation. Most infectious diarrhea is self-limiting and only requires supportive management. Viral agents are increasingly recognized as causative agents of epidemic and sporadic diarrhea. In developing countries, diarrhea is a major cause of mortality in children. Oral rehydration therapy, guided by a clinical assessment of the degree of dehydration, is cheap, simple, and effective and remains the mainstay of management of infant diarrhea. Controversies focus on the optimal formulation of oral rehydration solution. A vaccine against rotavirus has the potential to save millions of lives worldwide.

Improved serodiagnosis of Campylobacter jejuni infections using recombinant antigens

Campylobacter jejuni is a frequent cause of infectious diarrhoea and is increasingly recognized as a trigger for late-onset complications. The poor standardization of commonly used serological tests might explain the conflicting results regarding the frequency of antecedent C. jejuni infections in defined patient groups. In order to obtain reliable epidemiological data as to the role of C. jejuni in causing late-onset complications, a highly specific and sensitive diagnostic tool for the epidemiological investigation of C. jejuni-associated diseases was developed. It was shown that recombinant proteins encoded by the C. jejuni genes cj0017 (P39) and cj0113 (P18) are specifically recognized by antibodies in sera from patients with C. jejuni enteritis. An ELISA using recombinant P18 and P39 as antigens was 91.9% sensitive and 99.0% specific, with positive and negative predictive values of 97.1% and 97.0%, respectively, comparing favourably with the 27.0% sensitivity of a routinely used serological assay.

The HS:1 serostrain of Campylobacter jejuni has a complex teichoic acid-like capsular polysaccharide with nonstoichiometric fructofuranose branches and O-methyl phosphoramidate groups

Recently, the CPS biosynthetic loci for several strains of Campylobacter jejuni were sequenced and revealed evidence for multiple mechanisms of structural variation. In this study, the CPS structure for the HS:1 serostrain of C. jejuni was determined using mass spectrometry and NMR at 600 MHz equipped with an ultra-sensitive cryogenically cooled probe. Analysis of CPS purified using a mild enzymatic method revealed a teichoic acid-like [-4)-alpha-d-Galp-(1-2)-(R)-Gro-(1-P](n), repeating unit, where Gro is glycerol. Two branches at C-2 and C-3 of galactose were identified as beta-d-fructofuranoses substituted at C-3 with CH(3)OP(O)(NH(2))(OR) groups. Structural heterogeneity was due to nonstoichiometric glycosylation at C-3 of galactose and variable phosphoramidate groups. Identical structural features were found for cell-bound CPS on intact cells using proton homonuclear and (31)P heteronuclear two-dimensional HR-MAS NMR at 500 MHz. In contrast, spectroscopic data acquired for hot water/phenol purified CPS was complicated by the hydrolysis and subsequent loss of labile groups during extraction. Collectively, the results of this study established the importance of using sensitive isolation techniques and HR-MAS NMR to examine CPS structures in vivo when labile groups are present. This study uncovered how incorporation of variable O-methyl phosphoramidate groups on nonstoichiometric fructose branches is used in C. jejuni HS:1 as a strategy to produce a highly complex polysaccharide from its small CPS biosynthetic locus and a limited number of sugars.

An ATP-binding cassette-type cysteine transporter in Campylobacter jejuni inferred from the structure of an extracytoplasmic solute receptor protein

Campylobacter jejuni is a Gram-negative food-borne pathogen associated with gastroenteritis in humans as well as cases of the autoimmune disease Guillain-Barré syndrome. C. jejuni is asaccharolytic because it lacks an active glycolytic pathway for the use of sugars as a carbon source. This suggests an increased reliance on amino acids as nutrients and indeed the genome sequence of this organism indicates the presence of a number of amino acid uptake systems. Cj0982, also known as CjaA, is a putative extracytoplasmic solute receptor for one such uptake system as well as a major surface antigen and vaccine candidate. The crystal structure of Cj0982 reveals a two-domain protein with density in the enclosed cavity between the domains that clearly defines the presence of a bound cysteine ligand. Fluorescence titration experiments were used to demonstrate that Cj0982 binds cysteine tightly and specifically with a K(d) of approximately 10(-7) M consistent with a role as a receptor for a high-affinity transporter. These data imply that Cj0982 is the binding protein component of an ABC-type cysteine transporter system and that cysteine uptake is important in the physiology of C. jejuni.

Campylobacter, from obscurity to celebrity

After its successful isolation from stools in the 1970s, Campylobacter jejuni has rapidly become the most commonly recognised cause of bacterial gastroenteritis in man. Reported cases of human campylobacteriosis represent only a small fraction of the actual number. In industrialised countries, the incidence of C. jejuni/Campylobacter coli infections peaks during infancy, and again in young adults aged 15-44 years. Acute self-limited gastrointestinal illness, characterised by diarrhoea, fever and abdominal cramps, is the most common presentation of C. jejuni/C. coli infection. The introduction of selective media has made the diagnosis of Campylobacter enteritis a simple procedure. In general, Campylobacter enteritis is a self-limiting disease which seldom requires antimicrobial therapy, although one in 1000 infections may lead to the Guillain-Barré syndrome. In industrialised countries, most infections are acquired through the handling and consumption of poultry meat. In developing countries, where the disease is confined to young children, inadequately treated water and contact with farm animals are the most important risk factors. Many infections are acquired during travel. Fluoroquinolone resistance has been reported in C. jejuni since the late 1980s in Europe and Asia, and since 1995 in the USA. The use of fluoroquinolones to treat animals used for food has accelerated this trend of resistance. In Australia, where fluoroquinolones have not been licensed for use in food production animals, C. jejuni remains susceptible to fluoroquinolones. The public health burden of Campylobacter spp. other than C. jejuni/C. coli remains unmeasured. Better diagnostic methods may reveal the true health burden of these organisms.

Sensitivity and specificity of serology in determining recent acute Campylobacter infection

BACKGROUND

The measurement of serum antibodies to Campylobacter spp. has been used to investigate links between prior Campylobacter infections and the development of Guillain-Barre syndrome and its variants. Little is known of the serum antibody response to acute infections in the short- or long-term.

AIMS

The aims of the present study were to investigate the normal serum response to an acute Campylobacter infection and the sensitivity and specificity of anti-Campylobacter antibodies in determining recent Campylobacter infection.

METHODS

An enzyme-linked immunosorbent assay (ELISA) method was used to measure serum anti-Campylobacter immunoglobulin G (IgG), IgA and IgM antibodies. Controls consisted of 420 blood donors without recent gastroenteritis, 25 patients with other gastrointestinal infections, 24 patients with neurological conditions not affecting the peripheral nerves and 19 patients with autoimmune disorders. Three patient groups were assessed: 99 patients with acute Campylobacter infections, all of whom were tested 3 weeks post-infection; 69 of these patients tested 3-6 months later; and 74 additional patients tested >20 months post-infection. Western blot analysis was performed on controls and patients with high titre anti-Campylobacter antibodies to assess for cross-reactivity and specificity.

RESULTS

Following acute infections, all antibody classes rose in the majority of but not in all patients, followed by decreasing titres that did not return to baseline levels. Sixteen per cent of enteritis cases did not demonstrate a rise in titres and 9% of cases had significant levels of antibodies >20 months post-infection. The ELISA used was shown to be highly specific for the detection of Campylobacter antibodies.

CONCLUSION

The use of Campylobacter-specific antibody levels as the sole marker of prior infection is an unreliable method of determining the association between Campylobacter infection and neurological disease.

Prospective study of clinical epidemiology of Guillain–Barré syndrome in Harbin, China

Clinical manifestations, outcomes, prognostic indicators, and clinico-epidemiological subgroups were described based on the information of 71 patients with Guillain-Barré syndrome (GBS), who were identified from a prospective survey in Harbin, China during a 1-year period from 1 October 1997 to 30 September 1998. GBS diagnoses of the patients were validated by senior neurologists and most patients were followed up for 6 months after onset. Antecedent events, mainly respiratory infections, were found in 55 (78%) patients during the month before onset. The clinical features, like motor weakness as initial symptoms (82%) and tendon areflexia or hyporeflexia (100%), are similar to those reported from other populations. However, the proportion (70%) of patients reaching to nadir less than 7 days after onset was rather high. Intravenous human immunoglobulin and/or plasmapheresis were used in 45% of the patients and steroids in 58%. At 6 months after onset, 82% of the patients could walk without aid, 46% of the patients had no any residual signs. Four (6%) patients died within 1 month due to respiratory failure. Three subgroups with different clinico-epidemiological characteristics were identified by using cluster analysis. In conclusion, GBS patients in Harbin, China were younger, had shorter time to nadir, frequently preceded by a respiratory infection, and often treated with steroids. Clinical and epidemiological differences of GBS might exist between various populations.

Guillain-Barré syndrome associated with Campylobacter jejuni infection in England, 2000-2001

Guillain-Barré syndrome (GBS) is a rare but serious complication of infectious intestinal disease due to Campylobacter jejuni. To date, estimates of the burden of C. jejuni-associated GBS have been based on limited data regarding the proportion of GBS attributable to this pathogen. In this paper, we combine data obtained from Sweden and a large study of infectious intestinal disease with routine and surveillance data from England to estimate the number and proportion of GBS cases attributable to C. jejuni. We estimate that, between 1 April 2000 and 31 March 2001, symptomatic C. jejuni infection was responsible for 157 cases of GBS, constituting approximately 15% of all GBS cases in England.

Plasma immunoadsorption therapy for Guillain-Barré syndrome: critical day for initiation

Immunoadsorption plasmapheresis (IAPP) is a method of removing circulating immune factors that is used to treat Guillain-Barré syndrome (GBS). We retrospectively analyzed the data on our GBS patients. In 21 patients treated with IAPP, linear regression analysis showed that the time from the onset of symptoms to the initiation of IAPP was correlated with the time required for improvement by one Hughes functional grade. We investigated the critical day for initiating treatment, which we defined as the day when initiation of IAPP was significantly more likely to improve function by at least one Hughes grade when compared with the outcome in patients receiving supportive therapy (non-IAPP group). The critical day was found to be day 6 after the onset of GBS.

The structures of the lipooligosaccharide and capsule polysaccharide of Campylobacter jejuni genome sequenced strain NCTC 11168

Campylobacter jejuni infections are one of the leading causes of human gastroenteritis and are suspected of being a precursor to Guillain-Barré and Miller-Fisher syndromes. Recently, the complete genome sequence of C. jejuni NCTC 11168 was described. In this study, the molecular structure of the lipooligosaccharide and capsular polysaccharide of C. jejuni NCTC 11168 was investigated. The lipooligosaccharide was shown to exhibit carbohydrate structures analogous to the GM1a and GM2 carbohydrate epitopes of human gangliosides (shown below): The high Mr capsule polysaccharide was composed of beta-d-Ribp, beta-d-GalfNAc, alpha-d-GlcpA6(NGro), a uronic acid amidated with 2-amino-2-deoxyglycerol at C-6, and 6-O-methyl-d-glycero-alpha-l-gluco-heptopyranose as a side-branch (shown below): The structural information presented here will aid in the identification and characterization of specific enzymes that are involved in the biosynthesis of these structures and may lead to the discovery of potential therapeutic targets. In addition, the correlation of carbohydrate structure with gene complement will aid in the elucidation of the role of these surface carbohydrates in C. jejuni pathogenesis.

Antibodies to neuron-specific antigens in children with autism: possible cross-reaction with encephalitogenic proteins from milk, Chlamydia pneumoniae and Streptococcus group A

We measured autoantibodies against nine different neuron-specific antigens and three cross-reactive peptides in the sera of autistic subjects and healthy controls by means of enzyme-linked immunosorbent assay (ELISA) testing. The antigens were myelin basic protein (MBP), myelin-associated glycoprotein (MAG), ganglioside (GM1), sulfatide (SULF), chondroitin sulfate (CONSO4), myelin oligodendrocyte glycoprotein (MOG), alpha,beta-crystallin (alpha,beta-CRYS), neurofilament proteins (NAFP), tubulin and three cross-reactive peptides, Chlamydia pneumoniae (CPP), streptococcal M protein (STM6P) and milk butyrophilin (BTN). Autistic children showed the highest levels of IgG, IgM and IgA antibodies against all neurologic antigens as well as the three cross-reactive peptides. These antibodies are specific because immune absorption demonstrated that only neuron-specific antigens or their cross-reactive epitopes could significantly reduce antibody levels. These antibodies may have been synthesized as a result of an alteration in the blood-brain barrier. This barrier promotes access of preexisting T-cells and central nervous system antigens to immunocompetent cells, which may start a vicious cycle. These results suggest a mechanism by which bacterial infections and milk antigens may modulate autoimmune responses in autism.