Epidemiology of Guillain-Barré syndrome

Treatment for experimental autoimmune neuritis with clodronate (Bonefos)

Experimental autoimmune neuritis (EAN) serves as an animal model for human Gullain-Barre syndrome (GBS), an autoimmune disease causing demyelination and inflammation of peripheral nerves. Macrophages, which play a major role in this autoimmune inflammatory process, can be selectively targeted by high doses of bisphophonates. The goal of this study was to examine the effect of the bisphosphonate, clodronate, on the severity of the EAN model. EAN was induced in female adult rats by immunization with bovine peripheral myelin. A number of treatment protocols with clodronate were used based on the common dosage regimen of 20 mg/kg in humans starting with the appearance of clinical signs on day 10 post-immunization. The clinical parameters measured included a clinical score, a motor performance test performed on a Rotarod and body weight. The expression of the matrix metaloprotease (MMP-9) in the sciatic nerves was measured as a marker of inflammatory macrophages. Treatment with clodronate, 20 mg/kg daily and 40 mg/kg every 2 days, significantly reduced the disease severity (a 75% decrease in severity, p < 0.01 by ANOVA) as measured by the clinical score compared to controls. Performance on the Rotarod test and body weight confirmed the clinical score findings. MMP-9 expression levels were significantly lower in the sciatic nerves of clodronate-treated rats. The present findings support the efficiency of clodronate in inflammatory diseases of the peripheral nervous system. The mechanism of action includes inhibition of inflammatory macrophages. The results suggest the use of bisphosphonates be considered in humans with GBS.

Inhibition of Ras attenuates the course of experimental autoimmune neuritis

EAN induced in Lewis rats by immunization with peripheral bovine myelin was treated by the Ras inhibitor farnesylthiosalicylate (FTS). Treatment from day 0 with FTS (5 mg/kg intraperitoneally twice daily) attenuated peak clinical scores (mean+/-S.E., 2.5+/-0.5 compared to 4.1+/-0.5 in saline treated controls, p=0.018, t-test) but not recovery. Treatment from day 10 with FTS attenuated peak disability (2.5+/-0.6, p=0.032 compared to saline treated controls) and improved recovery (0.84+/-0.42, untreated controls 2.4+/-0.6, p=0.028 by repeated measures ANOVA). Effects were confirmed by rotarod and nerve conduction studies. An inactive analogue, geranylthiosalicylate, had no clinical effect. Inhibition of Ras is of potential use in the treatment of inflammatory neuropathies.

Guillain-Barre syndrome in Greece: seasonality and other clinico-epidemiological features

The epidemiologic and clinical features of Guillain-Barré syndrome (GBS) during a 13-year period in a region of south-western Greece with an average population of 819 009 inhabitants are described. Clinical records of all patients between 1 January 1989 and 31 December 2001 who were admitted in the two referring hospitals of the above district and fulfilled the criteria for idiopathic GBS were reviewed. Overall 105 patients were identified. The age adjusted to European population incidence rate per 100 000 person-years was 1.02 (95% CI: 0.84-1.24) and a male preponderance was found. The highest number of cases (35; 33.3%) occurred in spring and the lowest (17; 16.2%) in autumn, although this tendency did not reach a significant level. Cases with and without preceding illness were similarly distributed in the seasons. Electrophysiologic abnormalities of axonal type were found in 6.1% of patients. The mortality rate was 2.8% and the long-term outcome 5%. The incidence of GBS was relatively low and the prognosis was close to the best reported. Spring clustering has also been observed in other countries with mild climate.

A clinical and electrophysiologic survey of childhood Guillain-Barré syndrome

In this 16-year (1986-2001) retrospective study, 23 childhood patients were identified with Guillain-Barré syndrome. According to clinical and electrophysiologic findings, 18 patients manifested acute inflammatory demyelinating polyradiculoneuropathy, 2 had Miller Fisher syndrome, 1 had axonal forms, and 2 were unclassified. Seasonal preponderance was evident in 39% of patients with Guillain-Barré syndrome, developing the disease in the winter (November to January) with upper respiratory infection the most frequent preceding event. The most common manifestation was limb weakness, with various degrees of motor weakness in 22 patients. Bulbar involvement was the most common cranial palsy, and it was evident in 30% of the episodes. Only one of these progressed to mechanical ventilation during hospitalization. Altogether, approximately 61% of the episodes exhibited sensory symptoms. At a follow-up of 1 year or more, 20 patients recovered and 3 had residua. Furthermore, no fatality occurred in our study. Our study also demonstrates that the clinical course of childhood Guillain-Barré syndrome has a shorter recovery time as compared with an adult patient group. Therapeutic outcome is favorable for patients who receive prompt treatment.

Epidemiology of the Guillain-Barré syndrome

This review focuses on recent epidemiological findings on Guillain-Barré syndrome regarding incidence, antecedent events related to the disease, prognosis and prognostic indicators, and treatment. Moreover, this review summarizes recent observations on clinical variants of Guillain-Barré syndrome and their relationship with the prevailing clinical presentation of the disease. The epidemiological observations which have advanced the understanding of the pathogenesis of Guillain-Barré syndrome are also discussed.

Autonomic dysfunction in experimental autoimmune neuritis: heart rate

Autonomic nervous system (ANS) dysfunction occurs in more than half of Guillain--Barré syndrome (GBS) patients and is an important cause of death in the disease. In this study we examined heart rate (HR) changes in an animal model of GBS, experimental autoimmune neuritis (EAN), induced by immunization with myelin extracted from bovine spinal roots. The animals developed progressive motor weakness accompanied by significant weight loss and hypothermia. HR was measured in 33 EAN rats at rest (rHR) and followings stressful stimulation (sHR). Average pre-immunization rHR was 341+/-28 beats per minute (b.p.m.) and sHR was 486+/-21 bpm. Although the mean rHR in rats with EAN was not significantly different compared to that at baseline, there was a significant increase of variation of rHR with six rats demonstrating bradycardia (<280 b.p.m.) and 10 tachycardia (>400 b.p.m.) (P<0.01, F-test). sHR in EAN rats was significantly lower (P<0.01), suggesting sympathetic system impairment. These findings may serve as a basis for testing treatments of ANS dysfunction in EAN.

Guillain-Barré syndrome in Taiwan: a clinical study of 167 patients

OBJECTIVE

To identify clinical characteristics of various forms of Guillain-Barré syndrome in Taiwan.

METHODS

The clinical and electrophysiological data of 167 consecutive patients with Guillain-Barré syndrome admitted to Chang Gung Memorial Hospital, a general paediatric and adult hospital in Taiwan, were reviewed.

RESULTS

Analysis of age distribution disclosed a high incidence (21%) among patients under the age of 10 years. Seasonal preponderance in Spring (March to May) was found. Utilizing clinical and electrophysiological data, these 167 patients with Guillain-Barré syndrome were subclassified; 82 (49%) had acute inflammatory demyelinating polyradiculoneuropathy (AIDP), 32 (19%) had Fisher syndrome (FS), and six (4%) had axonal forms of Guillain-Barré syndrome. The remaining 47 (28%) patients were unclassified. Patients with AIDP and FS had many common clinical features, including seasonal distribution, history of preceding illness, sensory abnormalities, cranial nerve involvement except for extraocular motor nerves, and albuminocytological dissociation on examination of CSF. Follow up study on 145 patients disclosed that 127 (87%) recovered satisfactorily, 14 (10%) were persistently disabled, and four (3%) died during admission to hospital. Clinical features associated with poor outcome (persistent disability or death) were requirement for mechanical ventilation, a low mean compound muscle action potential amplitude (< or = 10% of the lower limit of normal), and age greater than 40 years.

CONCLUSION

Guillain-Barré syndrome in Taiwan showed a peculiar age and seasonal distribution and a high frequency of FS not seen in other series. Given that patients with AIDP and FS had many common clinical features, AIDP and FS may have similar underlying pathological mechanisms.

Guillain-Barré syndrome in Stockholm County, 1973-1991

In order to describe the incidence of Guillain-Barré syndrome (GBS) in Stockholm County (SC) and hospital use by GBS patients, we conducted a retrospective epidemiological study on GBS covering 1973-1991, using the Hospital Inpatient Register in SC. There were 556 patients, bona fide residents in the county during the study period, discharged from hospitals with GBS diagnosis. The mean annual incidence, age-adjusted to the European population, was 1.84 (2.15 for males and 1.57 for females) per 100,000 population. The incidence increased with age and showed a bimodal distribution with peaks in the 10-29 and 70-79 age-groups. Annual incidence rates were highest in 1978 and 1983. Neither heterogeneity of annual or monthly rates nor linear trends during the period were found to be significant, except in 1978 for patients below 40 years of age, RR 1.72 (95% CI 1.08-2.71) and in 1983 for patients at ages 40 years and over, RR 1.48 (95% CI 1.02-2.16), when compared with GBS incidences in the same age-groups during the remaining study period. The mean +/- SD duration of hospital stay, including long-term care or rehabilitation institutions, for GBS patients, was 86 +/- 210 days, with considerably longer duration for the elderly. The rate of hospital use by GBS patients was 162 days per 100,000 inhabitants per year. In accordance with results of prior studies in South-West Stockholm and described GBS epidemics in Sweden, this study supports that an etiologically different subgroup of GBS exists at ages below 40 years, and that relevant but small time-space variations, such as the reported zimeldine epidemic in 1983, resist detection by hospital data analysis of pooled GBS cases. Efficient epidemiological surveillance of GBS may require targeted development of clinico-epidemiological tools.

Guillain-Barré syndrome in south-west Stockholm, 1973-1991, 1. Quality of registered hospital diagnoses and incidence

We describe the incidence and explore the quality of registered diagnosis for Guillain-Barré syndrome (GBS) in a population-based retrospective study in South-West Stockholm (SWS), Sweden, during the period 1973-1991. We used data on registered hospital discharges and open-care visits, and from medical records. Medical records were available for 83 (80.6%) of 103 patients with registered GBS diagnosis at discharge from hospitals. For 69 (83.1%) of such patients, the information from the hospital record fulfilled the National Institute of Neurological and Communicative Disorders and Stroke (NINCDS) clinical criteria for GBS. One out-patient presented with suspected GBS. In contrast, none of 40 patients discharged with diagnosis of unspecific polyneuropathy fulfilled the above mentioned criteria. During the period 1973-1991, the mean annual incidence of GBS per 100,000 was 1.74, 95% CI 1.41-2.12, from register data and 1.49, 95% CI 1.19-1.85, after excluding those not fulfilling criteria for GBS. The age-adjusted incidence after validation was higher for men, 1.64, 95% CI 1.19-2.21, than for women, 1.46, 95% CI 1.05-1.99. An increasing incidence with age was found, presenting the age-specific curve a bimodal shape. The results of this study confirm that hospital discharge diagnostic data in Sweden can be used for purposes of epidemiological research and surveillance for GBS, and show that the incidence of GBS in SWS compares to those described in other populations.

Guillain-Barré syndrome in children: a cooperative study in Taiwan

Seventy-two children with Guillain-Barré syndrome (GBS), diagnosed at 11 major teaching hospitals in Taiwan during the period 1986-1990, were studied retrospectively. There were 44 males and 28 females ranging in age from 7 months to 15 years. Preceding events could be traced in 61 patients (85%), including antecedent infection in 59 patients and previous vaccination in 2. As well as the consistent pictures of progressive weakness and generalized hyporeflexia, there were sensory complaints (26%), cranial nerve lesions (46%), respiratory failure (14%) and autonomic dysfunction (25%). Motor symptoms reached a maximum within 20 days in 88% of the patients, with the plateau lasting less than 2 weeks in 75%, and became stable within 3 months in 76%. Overall outcome showed complete recovery in 73% of the patients within 6 months after onset. Four (5.6%) had recurrence, and there was no mortality. The present study revealed that the annual incidence of GBS in Taiwan can be estimated roughly as 0.66 per 100,000 and that the course of childhood GBS is relatively benign.

Guillain-Barré syndrome in Cantabria, Spain. An epidemiological and clinical study

Seventy-one patients with Guillain-Barré syndrome (GBS) were retrospectively selected from within a defined area (Cantabria) in northern Spain, from 1975 to 1988. Excluding two non-resident cases, epidemiological analysis was based on 69 cases. The annual incidence rates were stable during the 14-year period of study with an average incidence of 0.95 (age-adjusted, 0.86) cases per 100,000 population. No significant difference was found for sex, urban or rural residence and there was no significant seasonal clustering. Antecedent event were recorded in 57% of patients, the most frequent events being upper respiratory infection and gastroenteritis. No association between use of gangliosides and the syndrome was found. Eight patients had variant syndromes including Fisher's syndrome (2 cases), and axonal (4 cases) and sensory (2 cases) GBS. Recurrences occurred in 3 cases. Excluding nine patients with incomplete follow-up and two with Fisher's syndrome, clinical analysis was based on 60 cases. Patients were divided into three groups as a function of their peak weakness. Significant features of the severe group were a requirement for ventilation, presence of bulbar palsy or dysautonomia and a longer duration of the plateau phase. However, it was not possible at an early stage of the clinical course to predict future motor deficit. Four (6.7%) patients belonging to the severe group died during the acute phase of the disease. No specific treatment for GBS was given. Outcome was assessed by means of serial examination up to 24 months after the onset of symptoms using a functional scale. At 3, 6 and 24 months 70%, 46% and 12% of patients, respectively, had a poor outcome.(ABSTRACT TRUNCATED AT 250 WORDS)

Epidemiology of Guillain-Barré syndrome in children: relationship of oral polio vaccine administration to occurrence

Because a cluster of cases of Guillain-Barré syndrome followed a mass vaccination program using oral polio vaccine, a retrospective epidemiologic survey was carried out in southern California to examine the relationship between oral polio vaccine and Guillain-Barré syndrome. We also examined the yearly pattern of Guillain-Barré syndrome and compared rates of illness in different ethnic populations. The mean annual incidence of Guillain-Barré syndrome was 0.60 (95% confidence intervals 0.48 to 0.73) per 100,000 children under 15 years of age. There was no difference in incidence between boys and girls or between ethnic populations. The incidence was significantly higher in 2-year-old children than in any other age group (p < 0.05). The onset of Guillain-Barré syndrome was preceded by an infection in 71 (76%) of 93 children. In five children (5%) a vaccination was given within 8 weeks before illness onset. Only two children received the oral polio vaccine; the duration from vaccine administration to the onset of Guillain-Barré syndrome was 41 and 52 days, whereas the mean incubation time associated with infectious illnesses was 10.3 days. Strong evidence against a causal relationship between oral polio vaccine administration and Guillain-Barré syndrome is provided by the failure to find a correlation between the usual age of immunization with oral polio vaccine and the incidence of Guillain-Barré syndrome by age and the failure to find any children with onset of Guillain-Barré syndrome within 1 month of immunization with oral polio vaccine.

The epidemiology of inflammatory polyradiculoneuropathy. A critical review of the distribution, characteristics and outcome of the disease. Plasmapheresis Study Group

An outline of the principal reports dealing with the definition, distribution, course and treatment of the inflammatory polyradiculoneuropathies, including the Guillain-Barré syndrome (GBS) and chronic inflammatory demyelinating polyneuropathy (CIDP), is given. Current diagnostic criteria for GBS are reaffirmed while the diagnosis of CIDP lacks proper standardization. Then, the boundaries between the two disorders are ill-defined. While GBS is rare and homogeneously distributed across developed and developing countries, the prevalence rate of CIDP is unknown. Several antecedent events have been implicated in the pathogenesis of GBS; yet, except for the swine-flu vaccine, the relation between infectious or toxic agents and the occurrence of the disease is purely anecdotal. The only factors known to influence the outcome of GBS are age, severity of opening symptoms, abnormal electrophysiologic characteristics of peripheral nerve function, and plasmapheresis. However, responders and non-responders to current treatment are far from defined. Although similarities have been found between experimental allergic neuritis and experimental allergic encephalomyelitis, the degree of CNS impairment in patients with inflammatory polyradiculoneuropathies needs further refinement. To provide a tentative answer to some of the unsolved questions on inflammatory polyradiculoneuropathies, a multicenter cohort study on newly diagnosed patients submitted to standard clinical and laboratory evaluation, and given common therapeutic regimes, is awaited.

[Guillain-Barré-Strohl syndrome: prognostic factors]

The authors analysed retrospectively 29 in-patients with Guillain-Barré-Strohl syndrome intending to recognize severity indexes as far as the development of complications and death are concerned. Sensory signs, autonomic dysfunction, respiratory insufficiency, sphincteric disturbances and a longer time in hospital turned out to be severity indexes, when present in these patients.

The epidemiology of Guillain-Barré syndrome

Population-based studies of Guillain-Barré syndrome (GBS) give crude average annual incidence rates varying from 0.4 to 1.7 per 100,000 population. The reported incidence is influenced by the diagnostic criteria adopted as well as the thoroughness of case-finding. Variations in these account for some of the lack of uniformity between different studies. Data from the Mayo Clinic based on National Institute of Neurological Disorders and Stroke diagnostic criteria and thorough ascertainment methods gave a crude incidence of 1.7 per 100,000 per year (x 10(-5]. Incidence was higher in females (2.3 x 10(-5] than males (1.2 x 10(-5] as well as in older compared to younger people (3.2 x 10(-5) over age 60 and 0.8 x 10(-5) under age 18, respectively). The disease reached a nadir after onset at 8 days on average, and the illness lasted an average of 12 weeks. Most patients (75%) recovered completely. Recent epidemiological studies of GBS suggest no clear secular trend. Incidence does fluctuate with time but not clearly with season. In virtually all studies "triggering" factors are implicated, but they appear to be diverse, making it less likely, from an epidemiological perspective, that a single antigen is of etiological importance in GBS.

The idiopathic polyradiculoneuropathies: a historical guide to an understanding of the clinical syndromes

Recognition of the idiopathic polyradiculoneuropathies began with Graves, Landry and Dumenil who, respectively, suggested, implied and established the peripheral nervous system as a site of disease. Over the ensuing decades other neurologists separated the idiopathic disorders from neuropathies of known cause, poliomyelitis and myelopathies. Guillain, Barré and Strohl described the acute benign syndrome and its cerebrospinal fluid abnormalities. Haymaker & Kernohan solidified the features of the acute disorder as did Dyck et al and Prineas & McLeod for the relapsing and chronic conditions. Currently the idiopathic polyradiculoneuropathies are regarded as autoimmune in nature, clinically generalized with some cases having focal involvement, and of varying severity with only occasional fatalities. Neurologists are divided as to whether the acute and chronic disorders represent 2 different conditions or whether they are 2 forms in the spectrum of a single disorder. This author favors the concept of a single disorder with multifarious manifestations.

Late onset of Guillain-Barré syndrome

The Guillain-Barré syndrome (GBS) usually occurs within one month of the precipitating cause. It is the purpose of this paper to show that typical cases may, however, appear weeks to months later. We have reviewed the collected data on these cases and suggest that they provide evidence which is in favour of a humoral, rather than a cell-mediated, aetiology for GBS.

North West Thames Registry of Neurological Disease

A feasibility study has been carried out to determine whether a population-based registry of neurological disease can be eastablished using the Hospital (Inpatient) Activity Analysis (HAA) records for England and Wales. The study provides a valuable opportunity to use and test the HAA system. The neurological disease chosen was the Guillain-Barré-Strohl syndrome (GBS), because it would be expected that most patients would be admitted to hospital, and recurrent attacks or chronicity are rare. In this study it has been demonstrated that, for GBS, a neurological registry, based on HAA records, provided an excellent source of data to measure the incidence of the disease and potentially any change of incidence over time. The proportion of coding errors was found to be under 5%.

Guillain-Barré syndrome: its epidemiology and associations with influenza vaccination

The epidemiology of Guillain-Barré syndrome (GBS) and the associations of GBS with influenza vaccination are described based on review of three types of epidemiological data: case-control studies, incidence rate studies of GBS in well-defined populations, and surveillance data from a sentinel neurologist surveillance system of GBS in the United States. These data indicate that the crude annual incidence rate of GBS per 100,000 people ranges from 0.6 to 1.9 in different populations in widely scattered areas of the world. In general, incidence rates are higher with advancing age until about 75 years, higher for men than women, and higher for whites than blacks. No specific HLA antigen has been significantly associated with GBS in general, although HLA AW 30 and AW 31 have been associated with chronic relapsing polyneuritis. Important trigger agents of GBS include nonspecific respiratory and gastrointestinal infections and cytomegalovirus infection. Influenza infection and influenza vaccinations are not generally important trigger agents. A major exception to this is the occurrence of just under 1 excess case of GBS per 100,000 A/New Jersey influenza vaccinations administered in the United States, 1976-1977. A significant excess risk of GBS was not observed after administration of influenza vaccine in 1978-1979 and 1979-1980. The differences between the contents of and immunological reaction to A/New Jersey influenza vaccine and the more recent influenza vaccines deserve further study.

Clinical features of the Guillain-Barré syndrome

In a country-wide search for patients with Guillain-Barré syndrome (GBS) in Israel, 89 patients were found between 1969 and 1972 who met standardized diagnostic criteria. These cases, derived from a well defined population, were analyzed to provide a more accurate picture of the full range of clinical signs than is available from selected case series in the literature. Preceding illnesses, presenting symptoms, maximal neurological deficit, reflex changes, sensory deficit, cranial nerve, sphincter, respiratory, autonomic disturbances and spinal fluid changes were determined. Mortality was 5.6% which is lower than in many series. Alternatives to account for the apparent benignity of GBS in Israel were offered.