Intravenous immunoglobulin as therapy for pediatric Guillain-Barré syndrome

Updated consensus statement: Intravenous immunoglobulin in the treatment of neuromuscular disorders report of the AANEM ad hoc committee

Intravenous immune globulin (IVIG) is an immune-modulating biologic therapy that is increasingly being used in neuromuscular disorders despite the paucity of high-quality evidence for various specific diseases. To address this, the AANEM created the 2009 consensus statement to provide guidance on the use of IVIG in neuromuscular disorders. Since then, there have been several randomized controlled trials for IVIG, a new FDA-approved indication for dermatomyositis and a revised classification system for myositis, prompting the AANEM to convene an ad hoc panel to update the existing guidelines.New recommendations based on an updated systemic review of the literature were categorized as Class I-IV. Based on Class I evidence, IVIG is recommended in the treatment of chronic inflammatory demyelinating polyneuropathy, Guillain-Barré Syndrome (GBS) in adults, multifocal motor neuropathy, dermatomyositis, stiff-person syndrome and myasthenia gravis exacerbations but not stable disease. Based on Class II evidence, IVIG is also recommended for Lambert-Eaton myasthenic syndrome and pediatric GBS. In contrast, based on Class I evidence, IVIG is not recommended for inclusion body myositis, post-polio syndrome, IgM paraproteinemic neuropathy and small fiber neuropathy that is idiopathic or associated with tri-sulfated heparin disaccharide or fibroblast growth factor receptor-3 autoantibodies. Although only Class IV evidence exists for IVIG use in necrotizing autoimmune myopathy, it should be considered for anti-hydroxy-3-methyl-glutaryl-coenzyme A reductase myositis given the risk of long-term disability. Insufficient evidence exists for the use of IVIG in Miller-Fisher syndrome, IgG and IgA paraproteinemic neuropathy, autonomic neuropathy, chronic autoimmune neuropathy, polymyositis, idiopathic brachial plexopathy and diabetic lumbosacral radiculoplexopathy.

Child with Guillain-Barré Syndrome Responding to Plasmapheresis: A Case Report

Intravenous immunoglobulin (IVIG) has long been regarded as the first-line treatment for Guillain-Barré syndrome (GBS), with plasmapheresis only being reserved for severe cases or used as an additional therapy of unproven efficacy. Here, we present the case of a 9-year-old girl with acute motor axonal neuropathy (AMAN), a rapidly progressive subtype of GBS that caused her to fall into respiratory failure. The patient failed to show a response 10 days after starting IVIG, but showed rather quick improvement with plasmapheresis. She received a total of 5 sessions of plasmapheresis on alternate days over a course of 8 days. Before starting plasmapheresis, her muscle strength was 2/5 in both upper limbs and 1/5 in both lower limbs, and she was dependent on mechanical ventilation. Following the first session, her power improved from 2/5 to 4/5 in the upper limbs, and the gag and sucking reflexes were recovered. On day 3, after the second session was initiated, she was extubated successfully (having been on a ventilator for 2 weeks) and remained on continuous positive airway pressure for the next 48 h, after which she was on room air. In addition, she was having hypertension from the first day of the diagnosis (which was due to autonomic instability), which improved after clonidine to maintain her blood pressure. She was also initially having urinary retention, then was off Foley’s catheter. The patient was discharged from the hospital 2 weeks following the first session of plasmapheresis, with power grade 4/5 in both her upper and lower limbs. Her cranial nerves had recovered fully, and she was able to walk with aids.

Guillain-Barré syndrome in children: subtypes and outcome

OBJECTIVE

This study reviews the clinical features, subtypes, and outcomes of childhood Guillain-Barré syndrome (GBS).

METHODS

Fifty-four children who attended a tertiary care training and research hospital in Turkey were enrolled in the study.

RESULTS

The mean age was 6.5 ± 4.2 years and 32 patients (59.5%) were male. The most common subtype of GBS was acute inflammatory demyelinating polyneuropathy (AIDP), which was seen in 27 patients (50%). Having antecedent history, especially upper respiratory tract infection was significantly more common in AIDP (P = 0.028). Sensorial symptoms were significantly more frequent in axonal type GBS (P = 0.001). When we compare the demyelinating and axonal forms, all of the groups had favorable outcome.

CONCLUSION

The diagnosis of pediatric GBS can be delayed because of its variable presentation. Early admission to hospital and early treatment are important for decreasing the need for respiratory support and improving the outcome.

The usefulness of immunotherapy in pediatric neurodegenerative disorders: A systematic review of literature data

Immunotherapeutic strategies to treat neurodegenerative disorders have inspired the scientific community. The aim of our review is to address the translational aspects of neuroimmunology to describe the efficacy of immunotherapy in the treatment of pediatric neurodegenerative disorders. In the studies we analyzed IVIG were found to be efficient in the treatment of post-streptococcal neurodegenerative disorders, even if in PANDAS, plasma-exchange (PE) showed a higher efficiency. IVIG were also successfully used in ADEM and Guillan-Barré syndrome. In Sydenham Chorea the use of methylprednisolone was found in most cases as efficient as IVIG, while in Tourette's Syndrome, Colecoxib was successfully used in one patient. Pediatric Multiple Sclerosis seems to respond better to immunosuppressant agents (Mitoxantrone, Cyclophosphamide, Natalizumab), as well as Neuromyelitis optica (Rituximab, Mycofenolate). The importance of this review relies in the attempt to draw standardized guidelines for immunotherapy in pediatric neurodegeneratve disorders.

The Production Processes and Biological Effects of Intravenous Immunoglobulin

Immunoglobulin is a highly diverse autologous molecule able to influence immunity in different physiological and diseased situations. Its effect may be visible both in terms of development and function of B and T lymphocytes. Polyclonal immunoglobulin may be used as therapy in many diseases in different circumstances such as primary and secondary hypogammaglobulinemia, recurrent infections, polyneuropathies, cancer, after allogeneic transplantation in the presence of infections and/or GVHD. However, recent studies have broadened the possible uses of polyclonal immunoglobulin showing that it can stimulate certain sub-populations of T cells with effects on T cell proliferation, survival and function in situations of lymphopenia. These results present a novel and considerable impact of intravenous immunoglobulin (IVIg) treatment in situations of severe lymphopenia, a situation that can occur in cancer patients after chemo and radiotherapy treatments. In this review paper the established and experimental role of polyclonal immunoglobulin will be presented and discussed as well as the manufacturing processes involved in their production.

Pharmacologic agents for pediatric neuroimmune disorders

Autoimmune diseases make up a significant portion of the acute and chronic caseload of all pediatric neurologists. By comparing these diseases and their treatments side by side, common themes become evident. Therapeutic decisions follow patterns dependent on the clinical situation. Physicians must adapt therapy based on individual clinical responses. This article provides an overview of the current therapeutic options as they relate to the more common pediatric neuroimmune disorders.

Guillain-Barré syndrome in children: clinic, laboratorial and epidemiologic study of 61 patients

The aim of the study was to analyze the epidemiologic, clinical, laboratory and development profile of Guillain-Barré syndrome series studied at the Child Institute, between 1989 and 2000. From the 61 patients that fulfilled the selection criteria, aged between 7 months and 13 years old, no sexual or seasonal variation was observed. Clinical events prior to neurological symptoms (with an average time gap of 20.7 days) were observed in 62.3%, 55% had cranial nerve disturbances, 27.9% dysautonomic symptoms, and 27.9% respiratory dysfunction. Installation time varied from 2-40 days, plateau from 0-28 days and recuperation from 30-480 days; 94% of patients had a complete clinical recuperation. Electrophysiology in 20 patients disclosed an abnormal demyelination pattern in 15, an exclusively motor axonal pattern in 4 and a mixed pattern in 1 patient. The results obtained did not differ from those in the literature but it was observed that boys and older children had a longer recuperation time. It was not possible to correlate electroneurography with clinical abnormalities and evolution due to the reduced number of patients.

Guillain-Barre syndrome in southern Chinese children: 32 year experience in Hong Kong

BACKGROUND

The purpose of the present study was to investigate the clinical pattern of Guillain-Barre syndrome (GBS) in southern Chinese children in Hong Kong and to compare the clinical outcome of early versus delayed intervention with i.v. immunoglobulin (IVIg).

METHODS

A retrospective review of medical records of GBS patients admitted to two hospitals on Hong Kong Island during a 32 year period (1976-2008) was performed. Clinical outcome was compared for early versus late IVIg treatment, using a 7 day cut-off. This analysis was then repeated using a 10 day cut-off.

RESULTS

Of 34 children, 22 (65%) had preceding illness but no infective etiology could be identified. Nerve conduction was measured in 17 (50%): nine had demyelinating neuropathy, three had axonal neuropathy with demyelinating features, two had pure axonal neuropathy, and one was normal. In two patients with Miller-Fisher syndrome (MFS) the studies showed additional abnormal sensory conduction. Twenty-one received conservative treatment only. Ten (29%) received IVIg, two (6%) received plasmapheresis and three (9%) received corticosteroid. Thirty-one (91%) had complete recovery, two (6%) had long-term morbidity and one died of respiratory failure. Comparison of the early and late IVIg treatment groups for each cut-off showed no statistically significant difference in clinical outcome. A longer period of hospital stay and longer time to improve one disability grade, however, were noted for the late treatment group for both cut-offs.

CONCLUSIONS

The clinical profile of GBS in southern Chinese children in Hong Kong is provided. There was no statistically significant difference between early versus delayed treatment with IVIg.

IVIG therapy in neurological disorders of childhood

There is growing evidence that intravenous immunoglobulins (IVIG) are effective in some neuroimmunological disorders of childhood. This short review summarizes the evidence-based indications and recommendations of IVIG therapy in these disorders. Despite considerable efforts to define the role and mechanisms of IVIG, more clinical studies are needed to further explore the therapeutic potential of IVIG in childhood diseases of the nervous system and muscle.

Current Therapeutic Options in Severe Guillain-Barre?? Syndrome

The classical form of Guillain-Barré syndrome (GBS) refers to an acute monophasic demyelinating motor and sensory polyneuropathy characterized by symmetric ascending flaccid weakness, along with sensory impairment and, less commonly, autonomic perturbations. Pure motor axonal forms, axonal motor, and sensory forms, as well as pure autonomic forms, have also been identified. A complex immune-mediated process leads to segmental demyelination accompanied with axonal involvement in protracted cases. Establishing strategies of immunomodulation may therefore halt and even reverse the harmful autoimmune insult to peripheral nerves. The present article reviews the current immunomodulatory options in severe GBS. A recent Cochrane meta-analysis of 6 randomized studies showed no significant improvement using corticosteroids, including either oral or intravenous methylprednisolone. Combined methylprednisolone and immunoglobulins shortened the time lapse to regain independent walking. Plasmapheresis (PE) was the first effectively proven method of immunomodulation, followed by intravenous immunoglobulins (IVIG). Both methods are comparable in their beneficial effect and were used either separately or in combination, but PE was more frequently associated with severe adverse effects requiring cessation of therapy, including a bleeding diathesis. In addition, PE is feasible only in major referral centers requiring the appropriate equipment and trained personnel. In addition, younger children may be at risk for bleeding after insertion of wide catheters. Therefore, in cases of severe GBS, IVIG is recommended as the first-line drug using a total empiric dose of 2 g/kg administered over 2 consecutive days, especially in children proven highly effective with negligible adverse effects. In protracted cases, the addition of intravenous corticosteroids to IVIG should be considered, which may shorten the duration to regain independent walking. If such therapy fails, PE should be applied using centrifugal blood separators with 5% albumin as the substitute solution.

Intravenously administered immunoglobulin in the treatment of childhood Guillain-Barré syndrome: a randomized trial

OBJECTIVE

To determine the optimal treatment for childhood Guillain-Barré syndrome (GBS).

METHODS

We performed a randomized, multicenter study of GBS according to international diagnostic criteria. In study 1 (early treatment), children able to walk unaided for 5 meters were randomized for 1 g/kg intravenously administered immunoglobulin (IVIG) over 2 days or no treatment. The primary outcome measure was the degree of disability at nadir. In study 2 (treatment for severe GBS), children unable to walk 5 meters unaided were randomized for 1 g/kg IVIG over 2 days or 0.4 g/kg IVIG over 5 days. The primary outcome measure was the number of days needed to regain the ability to walk unaided. Children randomized for no treatment in study 1 could enter study 2 if loss of unaided walking occurred.

RESULTS

Ninety-five children with GBS were registered in 40 months. Twenty-one children were randomized in study 1 and 51 in study 2 (5 after deterioration in study 1). Twenty-eight children were not randomized for various reasons. Eleven of 21 patients in study 1 lost the ability to walk unassisted and 6 were bedridden, with no statistically significant difference between the children initially randomized for treatment versus no treatment. Recovery occurred faster in the group randomized for early treatment. In study 2, recovery did not differ significantly between the children treated for 2 days versus 5 days (median time to unaided walking: 19 days vs 13 days). Secondary transient deterioration in the disability score occurred more frequently in the group with the 2-day regimen than in the group treated for 5 days (5 of 23 patients vs 0 of 23 patients). Multivariate analysis with Cox regression showed that disease severity at the nadir was the only prognostic factor for recovery.

CONCLUSIONS

Treatment with IVIG before loss of unaided walking did not give rise to a less severe course, but recovery occurred somewhat faster. However, given the small number of patients, the power of this conclusion is low. For treatment after loss of unaided walking, there was no significant difference in the effectiveness of 2 g/kg IVIG administered over 2 days versus 5 days. Early "relapses" occurred more frequently after the shorter treatment regimen.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Intravenous immunoglobulins in severe Guillian-Barre syndrome in childhood

OBJECTIVE

This is a retrospective analysis of 25 children with severe Guillain-Barre syndrome admitted to our PICU.

METHOD

All children were treated with intravenous immunoglobulins (IVIG) in a dose of 2 g/kg body weight over 2-5 days in addition to supportive and respiratory care. Seventeen children were elective admissions to the PICU whereas 8 children were transferred from other hospitals in a critical condition. Five of 8 of the late referrals died as compared to none of the elective admissions.

RESULT

All 8 of the late referrals required mechanical ventilation as against 3 of the 17 elective admissions. Mean duration of PICU stay in the late referrals was 27 days as compared to 15 days in the elective admissions.

CONCLUSION

The authors concur with previously published reports, that early use of IVIG could reduce the mortality and the need for intubation and mechanical ventilation.

Outcome of axonal and demyelinating forms of Guillain-Barré syndrome in children

Previous reports have suggested that outcome is worse in the axonal compared with the demyelinating form of Guillain-Barré syndrome (GBS). We performed a retrospective study of 23 children with electrophysiologically confirmed cases of predominant subtypes of GBS to investigate this issue. The patients were classified based on the electrodiagnostic features: Ten (44%) had acute inflammatory demyelinating polyradiculoneuropathy, eight (35%) had acute motor axonal neuropathy, and five (21%) had acute motor-sensory axonal neuropathy. All patients received a standard intravenous immunoglobulin therapy (0.4 g /kg /day for 5 consecutive days). In the acute phase of the disease, patients with the axonal forms of GBS were more disabled than were those with the demyelinating GBS, as measured by GBS scores. Mechanical ventilation was required in five (38%) patients in the axonal group compared with one (10%) patient in the demyelinating group. There was no significant difference at 6 months in GBS scores between demyelinating and axonal forms of GBS. All 20 survivors recovered completely by 12 months. After standard intravenous immunoglobulin therapy, children with axonal forms of GBS recover more slowly than those with the demyelinating form, but outcome at 12 months appears to be equally favorable in two groups.

Outcome of severe Guillain-Barré syndrome in children: comparison between untreated cases versus gamma-globulin therapy

The objective of this study was to assess retrospectively the outcome of children with severe Guillain-Barré syndrome (GBS) treated either with intravenous immunoglobulins (IVIG) versus practically untreated cases by a known beneficial agent. Twenty-three children with severe GBS who became bedridden (i.e., Motor Disability Grading Scale [MDGS] grade of at least 4) were analyzed. Fifteen children were treated with IVIG and eight children comprised the nontreatment group: five on supportive therapy and three treated previously with oral steroids found ineffective in GBS. IVIG was administered at a dosage of 1 g/kg daily for 2 days under constant monitoring, with no adverse effects requiring cessation of therapy. Improvement by 1 grade on the MDGS after IVIG therapy was achieved in the IVIG group after a mean of 10.17 days (median, 8 days), and patients started walking independently after a mean of 30.35 days (median, 20.5 days). Improvement by 1 grade on the MDGS was achieved in the nontreatment group after a mean of 22.3 days (median, 20.3 days), and they started to walk independently after a mean of 113.3 days (median, 100 days). A significant difference could not be delineated between both groups, given the rather small number of children in each group. These results indicate a possible beneficial effect of IVIG in severe childhood-onset GBS compared with the nontreated group of children. The authors therefore recommend using IVIG as the first-line drug in such cases, which warrant further approval after double-blind controlled studies of using different IVIG regimens or combined with plasmapheresis and steroids.

GB syndrome with herpes simplex infection

G.B. Syndrome is an acute flaccid lower motor neuron (LMN) paralysis. The diagnosis is based on clinical presentation, course of illness with supportive investigations. This article reports an uncommon case of GB Syndrome caused by HSV infection in a 2 yr-9 mth-old child and have analysed the natural history, etiopathology, treatment and prognosis of the disease.

[Intravenous immunoglobulin in children with Guillain-Barré syndrome]

We report our experience with intravenous immunoglobulin (IVIG), plasmapheresis and supportive care in 13 patients with the Guillain-Barré syndrome. Seven of 13 patients received IVIG, 2 plasmapheresis and 4 supportive care. At 15th day after IVIG administration, all patients in this group had improved at least one disability grade. In the plasmapheresis group, 1 improved at 5th day after the procedure. Two of the 4 patients that received supportive care improved at 20th day of evaluation. In the IVIG group, the final scores were lower and had no relapses. These results suggest faster clinical improvement with IVIG when compared with supportive measures.

Guillain-Barré syndrome: perspectives with infants and children

An acute flaccid paraparesis or ascending quadriparesis in an infant or child constitutes a very important pediatric neurology emergency. The Guillain-Barré syndrome (GBS) is the most frequent cause. This is primarily an autoimmune, post-infectious, demyelinating, peripheral nervous system process. A small percentage of children develop a primary axonal process not unlike that identified more commonly in China. Because of the potential for acute respiratory compromise, any child suspected of having GBS needs immediate hospitalization. The major considerations in differential diagnosis include transverse myelitis, toxic neuropathies, tick paralysis, infantile botulism, myasthenia gravis, and dermatomyositis. On occasion, some younger children present with an acute severe pain syndrome that may mask as a pseudo-encephalopathy. Another clinical variant is the Miller-Fisher syndrome characterized by ataxia, ophthalmoparesis, and areflexia. This is associated with a high frequency of the anti-GQ-1-b antibodies. Although most children with GBS have a relatively benign clinical course, some become very ill and require intubation with intensive care monitoring. Immunomodulating treatment should be used for any child who loses the ability to walk. To date, no well-controlled study has been completed analyzing the relative merits of the two most commonly used therapies, namely plasmapheresis or intravenously administered immunoglobulin.

Neuromuscular disorders of childhood

Neuromuscular disorders are common causes of weakness and hypotonia in the infantile period and in childhood. Accurate diagnosis of specific neuromuscular disorders depends first on identification of which aspect of the peripheral neuromuscular system is affected--the motor neuron in the spinal cord, the nerve root or peripheral nerve, the neuromuscular junction, or the muscle--and then on the determination of the etiology and specific clinical entity. This review provides an overview of the major neuromuscular disorders of childhood with attention to recent advances and emerging areas of research.

Intravenous immunoglobulin in very severe childhood Guillain-Barré syndrome

To evaluate intravenous immunoglobulin (IVIG) therapy in children with very severe Guilain-Barré syndrome (GBS) with reference to the need for respiratory support, ICU stay and long-term outcome, we studied 33 children with very severe GBS and quadriparesis and/or respiratory muscle weakness admitted to the Pediatric Intensive Care Unit (PICU) of PGIMER, Chandigarh. Cases (n = 22, IVIG group) were enrolled prospectively, and controls (n = 11), similar to cases in age and severity of illness, retrospectively. All children received similar supportive and respiratory care. In addition, cases were given IVIG (Sandoglobulin, Sandoz) 0.4 g/kg bodyweight per day for 5 days. The mean age, duration of symptoms prior to admission and severity of illness in the two groups were similar. In the IVIG group, onset of recovery of muscle power was significantly earlier (day 14.8 (6.8) of illness vs day 20.9 (8.6), p < 0.05) and the length of PICU stay significantly shorter (20.5 (13.0) days vs 50.5 (33.3) days, p < 0.01). Sixteen (72.7%) children in the IVIG group had improved by at least one functional grade after 1 month and 15 (68%) were walking independently after 3 months compared with two (18%) and four (36%) controls, respectively (p < 0.05). The number of children who needed endotracheal intubation and mechanical ventilation and the duration of mechanical ventilation was significantly less in the IVIG-treated group. We conclude that in very severe GBS in children IVIG therapy improves outcome to a remarkable extent, reduces the need for intubation and mechanical ventilation, shortens the length of stay in ICU, and promotes ambulation sooner.