Guillain-Barré syndrome as the first presentation of human immunodeficiency virus infection

Immunoglobulin unresponsive Guillain-Barré syndrome: rinse or repeat? A systematic review

Introduction

Severe Guillain-Barré syndrome (GBS) patients may not show improvement after a single course of intravenous immunoglobulin (IVIg) therapy. Current treatment options include either a second course of IVIg or therapeutic plasma exchange (TPE). This systematic review aims to evaluate the current literature on the use of a second course of IVIg or TPE in patients who fail to show clinical improvement after the first IVIg course.

Methods

We searched PubMed, Embase and Medline databases up until 26 October 2023. Studies that evaluated adult patients with confirmed GBS who have failed one full course of IVIg and subsequently received either repeat IVIg or TPE were included. Risk of bias was performed using study-specific checklists. A narrative synthesis of results is presented.

Results

A total of 37 articles were identified (1 randomised controlled trial (RCT), 3 observational and 33 case reports/series), consisting of 422 patients in total. 12 studies evaluated repeat IVIg and 24 studies evaluated TPE after IVIg. There was no superiority of a repeat course of IVIg or TPE in all clinical outcome measures.

Conclusions

The evidence suggests with a low degree of certainty that there is no beneficial effect of further IVIg in unresponsive GBS. The quality of evidence regarding TPE after IVIg is insufficient to suggest any efficacy due to a lack of RCTs. We recommend standardised case reporting with consideration for a multinational case registry and RCTs to determine the efficacy of TPE after initial IVIg unresponsiveness.

Explore genetic susceptibility association between viral infections and Guillain-Barré syndrome risk using two-sample Mendelian randomization

BACKGROUND

Numerous observational studies have indicated that patients with Guillain-Barré syndrome (GBS) frequently had infections with various pathogens before the onset of the disease, particularly several viral infections. Some of these infections are linked to specific clinical and immunological subgroups of GBS, suggesting a potential correlation between viral infections and the development of GBS. However, observational studies have several limitations, including the presence of confounding factors.

METHOD

We explored the potential correlation between HIV, SARS-CoV-2, varicella-zoster virus, herpes simplex virus, Epstein-Barr virus, hepatitis B virus, and influenza virus with GBS using a two-sample Mendelian randomization approach. The data was derived from published summary statistics from genome-wide association studies (GWAS). After removing linkage disequilibrium, selecting strong instrumental variables and addressing confounding factors, we would conduct a two-sample Mendelian randomization analysis along with sensitivity testing and the MR-Steiger directional test.

RESULT

HIV may have a causal association with GBS (IVW: p = 0.010, OR [95% CI] 1.240 [1.052-1.463]), while no such relationship exists with COVID-19 (IVW: p = 0.275, OR [95% CI] 0.831[0.596-1.159]), varicella (IVW: p = 0.543, OR [95% CI] 0.919 [0.701-1.206]), herpes zoster (IVW: p = 0.563, OR [95% CI] 0.941 [0.766-1.156]), HSV (IVW: p = 0.280, OR [95% CI] 1.244 [0.837-1.851]), EBV (IVW: p = 0.218, OR [95% CI] 0.883 [0.724-1.076]), HBV (IVW: p = 0.179, OR [95% CI] 1.072 [0.969-1.187]), or influenza virus (IVW: p = 0.917, OR [95% CI] 0.971 [0.553-1.703]). We did not find any abnormal SNPs, pleiotropy, or heterogeneity, nor is there any reverse causation.

CONCLUSION

Our study results indicate a causal relationship between HIV and GBS, providing new research directions for the etiology of GBS.

Machine learning in the prediction of post-stroke cognitive impairment: a systematic review and meta-analysis

Objective

Cognitive impairment is a detrimental complication of stroke that compromises the quality of life of the patients and poses a huge burden on society. Due to the lack of effective early prediction tools in clinical practice, many researchers have introduced machine learning (ML) into the prediction of post-stroke cognitive impairment (PSCI). However, the mathematical models for ML are diverse, and their accuracy remains highly contentious. Therefore, this study aimed to examine the efficiency of ML in the prediction of PSCI.

Methods

Relevant articles were retrieved from Cochrane, Embase, PubMed, and Web of Science from the inception of each database to 5 December 2022. Study quality was evaluated by PROBAST, and c-index, sensitivity, specificity, and overall accuracy of the prediction models were meta-analyzed.

Results

A total of 21 articles involving 7,822 stroke patients (2,876 with PSCI) were included. The main modeling variables comprised age, gender, education level, stroke history, stroke severity, lesion volume, lesion site, stroke subtype, white matter hyperintensity (WMH), and vascular risk factors. The prediction models used were prediction nomograms constructed based on logistic regression. The pooled c-index, sensitivity, and specificity were 0.82 (95% CI 0.77-0.87), 0.77 (95% CI 0.72-0.80), and 0.80 (95% CI 0.71-0.86) in the training set, and 0.82 (95% CI 0.77-0.87), 0.82 (95% CI 0.70-0.90), and 0.80 (95% CI 0.68-0.82) in the validation set, respectively.

Conclusion

ML is a potential tool for predicting PSCI and may be used to develop simple clinical scoring scales for subsequent clinical use.

Systematic Review Registration

https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=383476.

The Peculiarity of Infection and Immunity Correlated with Guillain-Barré Syndrome in the HIV-Infected Population

Guillain-Barré syndrome (GBS) can occur at all stages of human immunodeficiency virus (HIV) infection. HIV, cytomegalovirus (CMV), and varicella zoster virus (VZV) are the main infectious agents in HIV-positive GBS cases. These cases include acute and chronic HIV infection, immune reconstitution inflammatory syndrome (IRIS) shortly after anti-retroviral therapy (ART), those with ART interruption, or those with cerebrospinal fluids (CSF) HIV escape. The mechanisms are involved in both humoral and cellular immunities. Demyelinating and axonal neuropathies are the main pathological mechanisms in GBS. Presentation and prognosis are identical to those in patients without HIV infection. Typical or atypical clinical manifestations, CSF analysis, electrophysiological and pathological examination, and antiganglioside antibody detection can help diagnose GBS and classify its various subtypes. Intravenous immunoglobulin and plasma exchange have been used to treat GBS in HIV-positive patients with a necessary ART, while ganciclovir or foscarnet sodium should be used to treat ongoing CMV- or VZV-associated GBS. Steroids may be beneficial for patients with IRIS-related GBS. We reviewed HIV-positive cases with GBS published since 2000 and summarized their features to highlight the necessity of HIV testing among patients with GBS. Moreover, the establishment of a multidisciplinary team will guarantee diagnostic and therapeutic advantages.

Difficulties of differential diagnosis of polyneuropathy developed after Gam-COVID-Vac vaccination on the background of combined infectious pathology (clinical case)

   The clinical case describes the difficulties of differential diagnosis of polyneuropathy that developed after Gam-Covid-Vac vaccination on the background of combined infectious pathology (HIV infection, tick-borne borreliosis, COVID-19) in a young woman. It is shown that various infectious and non-infectious diseases with similar clinical symptoms (peripheral nervous system affliction) occurring simultaneously in one patient can significantly affect each other’s course and complicate the establishment of the true cause of polyneuropathy. It should be noted that in this example, the establishment of a final diagnosis was carried out collectively, by consensus, and was based on the effectiveness of etiotropic (antibacterial) treatment, which in fact was an ex juvantibus therapy option, which made it possible to establish the most probable etiology of polyneuropathy – tick-borne borreliosis. In turn, HIV infection and possibly vaccination, according to the authors, could cause immunosuppression, which affected the degree of dissemination of Borrelia burgdorferi. It is also likely that the insufficient immune response in combination with the cascade plasma filtration session affected the initial dubious results of the serological tests, which further complicated the diagnosis.

Intravenous immunoglobulin therapy for HIV-associated Guillain-Barré syndrome

OBJECTIVE

To compare the efficacy of intravenous immunoglobulin (IVIG) added to antiretroviral therapy (ART) and ART alone in people living with human immunodeficiency virus-associated Guillain-Barré syndrome (HIV-associated GBS).

METHODS

The study was a retrospective analysis of clinical records of HIV-associated GBS patients from department of neurology at West China Hospital between January 2015 and October 2020. Patients treated with ART alone were compared with those treated with IVIG + ART. The primary outcome was the GBS disability score at 4 weeks, which was assessed with multivariable ordinal regression. Additional outcomes include the GBS disability scale at 1 week, improvement of ≥ 1 point on the GBS disability score at 1 and 4 weeks, median change in the MRC sum score at 1 and 4 weeks, number of patients who were able to walk independently at 4 weeks.

RESULTS

Two hundred and fifty-two (252) individuals living with HIV were recruited in the study. According to the inclusion and exclusion criteria, 21 HIV-associated GBS patients were finally included, of whom 8 were treated with IVIG + ART and 13 were treated with ART alone. At the fourth weeks after treatment, the GBS disability scale grade was significantly lower in patients treated with IVIG + ART than those with ART alone (1 vs. 2, P = 0.02). The adjusted OR for a lower GBS disability scale was 10.6 (95 % CI 1.15 to 98.05; P = 0.03) for the IVIG + ART group. Moreover, 6 of 8 (75 %) patients treated with IVIG + ART were able to walk independently at four weeks after treatment.

CONCLUSIONS

The introduction of IVIG combined with ART may be efficacious in the treatment of HIV-infected GBS and may provide better clinical outcomes.

The importance of neopterin in COVID-19: The prognostic value and relation with the disease severity

Coronavirus Disease 2019 [COVID-19], caused by severe acute respiratory syndrome coronavirus 2 [SARS-CoV-2], has rapidly evolved into a global health emergency. Neopterin [NPT], produced by macrophages when stimulated with interferon [IFN-]gamma, is an essential cytokine in the antiviral immune response. NPT has been used as a marker for the early assessment of disease severity in different diseases. The leading cause of NPT production is the pro-inflammatory cytokine IFN-. Macrophage activation has also been revealed to be linked with disease severity in SARS-CoV-2 patients. We demonstrate the importance of NPT in the pathogenesis of SARS-CoV-2 and suggest that targeting NPT in SARS-CoV-2 infection may be critical in the early prediction of disease progression and provision of timely management of infected individuals.

Post-Infectious Autoimmunity in the Central (CNS) and Peripheral (PNS) Nervous Systems: An African Perspective

The direct impact and sequelae of infections in children and adults result in significant morbidity and mortality especially when they involve the central (CNS) or peripheral nervous system (PNS). The historical understanding of the pathophysiology has been mostly focused on the direct impact of the various pathogens through neural tissue invasion. However, with the better understanding of neuroimmunology, there is a rapidly growing realization of the contribution of the innate and adaptive host immune responses in the pathogenesis of many CNS and PNS diseases. The balance between the protective and pathologic sequelae of immunity is fragile and can easily be tipped towards harm for the host. The matter of immune privilege and surveillance of the CNS/PNS compartments and the role of the blood-brain barrier (BBB) and blood nerve barrier (BNB) makes this even more complex. Our understanding of the pathogenesis of many post-infectious manifestations of various microbial agents remains elusive, especially in the diverse African setting. Our exploration and better understanding of the neuroimmunology of some of the infectious diseases that we encounter in the continent will go a long way into helping us to improve their management and therefore lessen the burden. Africa is diverse and uniquely poised because of the mix of the classic, well described, autoimmune disease entities and the specifically "tropical" conditions. This review explores the current understanding of some of the para- and post-infectious autoimmune manifestations of CNS and PNS diseases in the African context. We highlight the clinical presentations, diagnosis and treatment of these neurological disorders and underscore the knowledge gaps and perspectives for future research using disease models of conditions that we see in the continent, some of which are not uniquely African and, where relevant, include discussion of the proposed mechanisms underlying pathogen-induced autoimmunity. This review covers the following conditions as models and highlight those in which a relationship with COVID-19 infection has been reported: a) Acute Necrotizing Encephalopathy; b) Measles-associated encephalopathies; c) Human Immunodeficiency Virus (HIV) neuroimmune disorders, and particularly the difficulties associated with classical post-infectious autoimmune disorders such as the Guillain-Barré syndrome in the context of HIV and other infections. Finally, we describe NMDA-R encephalitis, which can be post-HSV encephalitis, summarise other antibody-mediated CNS diseases and describe myasthenia gravis as the classic antibody-mediated disease but with special features in Africa.