Tryptophan-immobilized column adsorbs immunoglobulin G anti-GQ1b antibody from Fisher's syndrome: A new approach to treatment

Anti-glutamic acid decarboxylase antibody positive neurological syndromes

A rare kind of antibody, known as anti-glutamic acid decarboxylase (GAD) autoantibody, is found in some patients. The antibody works against the GAD enzyme, which is essential in the formation of gamma aminobutyric acid (GABA), an inhibitory neurotransmitter found in the brain. Patients found with this antibody present with motor and cognitive problems due to low levels or lack of GABA, because in the absence or low levels of GABA patients exhibit motor and cognitive symptoms. The anti-GAD antibody is found in some neurological syndromes, including stiff-person syndrome, paraneoplastic stiff-person syndrome, Miller Fisher syndrome (MFS), limbic encephalopathy, cerebellar ataxia, eye movement disorders, and epilepsy. Previously, excluding MFS, these conditions were calledhyperexcitability disorders. However, collectively, these syndromes should be known as "anti-GAD positive neurological syndromes." An important limitation of this study is that the literature is lacking on the subject, and why patients with the above mentioned neurological problems present with different symptoms has not been studied in detail. Therefore, it is recommended that more research is conducted on this subject to obtain a better and deeper understanding of these anti-GAD antibody induced neurological syndromes.

Fisher syndrome with delayed facial weakness and taste impairment: a case report

A 55-year-old man was admitted to our hospital because of acute onset of diplopia and gait disturbance. On admission, ophthalmoplegia, ataxia and areflexia were observed. He was diagnosed with Fisher syndrome and given intravenous immunoglobulin therapy from day 6 to day 10 after disease onset. After treatment, ophthalmoplegia and ataxia began to improve. However, he developed taste impairment on day 13 and right hemifacial weakness on day 16 after onset. A blink reflex test revealed right facial nerve impairment. On day 42 after onset, facial weakness and taste impairment remitted, and the blink reflex test result was normalized without additional treatment. Although it has been known that 10% of patients with Fisher syndrome complicated by delayed facial nerve palsy, the mechanism of the facial nerve palsy has not been elucidated. Therefore, this is a significant report to describe delayed facial nerve palsy combined with taste impairment and successive recordings of blink reflex and facial nerve conduction in a patient with Fisher syndrome.

Dramatic recovery of steroid-refractory relapsed multiple sclerosis following Fingolimod discontinuation using selective immune adsorption

BACKGROUND

Selective immune adsorption (SIA) is an emerging method for treating immune-mediated neurological diseases, given its superior safety profile compared to plasma exchange (PEX). However, the available literature concerning Multiple Sclerosis includes no cases of SIA applied to steroid-refractory rebound after Fingolimod discontinuation.

CASE PRESENTATION

Here we report the case of a 32-year-old woman suffering from multiple sclerosis treated with Fingolimod and admitted to a Multiple Sclerosis Centre after drug discontinuation due to the occurrence of lymphopenia. During the few weeks preceding admission, the patient experienced progressive and severe neurological deterioration that did not respond to an initial cycle of pulsed high doses of intravenous 6-methyl prednisolone (IVMP). Given the ineffectiveness of a second cycle of IVMP, the patient was treated with plasma immunoadsorption, leading to dramatic functional recovery. The patient then started a neuro-rehabilitation program. About one month after the final SIA procedure the patient started Natalizumab-based therapy, while maintaining a stable neurological condition. We noted significant modification of C3/C4 complement components and total gamma globulin concentrations (IgG) during SIA.

CONCLUSIONS

Our observations show that however serious, steroid-refractory neurological deterioration occurring after Fingolimod discontinuation in multiple sclerosis can be treated with selective immune-adsorption therapy which thus represents a good alternative in these cases. It could be speculated that this clinical condition was associated with pattern II of demyelination, given the good response to a form of treatment that acts on autoantibodies. Thus, SIA represented an effective therapeutic strategy for this case of relapsed MS as steroid-resistent rebound post Fingolimod cessation.

Tryptophan complexed hydroxyapatite nanoparticles for immunoglobulin adsorption

The selective removal of immunoglobulin using different affinity-type particulate adsorbents has clinical significance in certain autoimmune diseases. This study reports the use of modified nanosized hydroxyapatite as a matrix for affinity based immunoglobulin adsorption. The adsorbent matrix consists of cyclodextrin complexed hydroxyapatite nanoparticles modified with tryptophan. It appears that presence of cyclodextrin has a synergic effect in the adsorption of immunoglobulin proteins having affinity with tryptophan complexed hydroxyapatite. The complexes were analyzed by X-ray diffraction (XRD), transmission electron microscopy (TEM), Fourier transform infrared (FT-IR) spectroscopy, thermal gravimetric analysis (TG) and differential scanning analysis (DSC) methods. The preferential affinity of the immunoglobulin towards tryptophan complexed particles was confirmed with polyacrylamide gel electrophoresis (PAGE) and Lowry adsorption techniques. Immunoglobulin adsorption was confirmed by quantitative turbidimetric assay using a standard immunoglobulin kit. The cytotoxicity index of the nanoparticle complexes were evaluated by MTT assay. Our proposed matrix for immunoglobulin adsorption is cost effective and adaptable for applications towards plasma perfusion.

Clinical and immunological spectrum of the Miller Fisher syndrome

The Miller Fisher syndrome (MFS), characterized by ataxia, areflexia, and ophthalmoplegia, was first recognized as a distinct clinical entity in 1956. MFS is mostly an acute, self-limiting condition, but there is anecdotal evidence of benefit with immunotherapy. Pathological data remain scarce. MFS can be associated with infectious, autoimmune, and neoplastic disorders. Radiological findings have suggested both central and peripheral involvement. The anti-GQ1b IgG antibody titer is most commonly elevated in MFS, but may also be increased in Guillain-Barré syndrome (GBS) and Bickerstaff's brainstem encephalitis (BBE). Molecular mimicry, particularly in relation to antecedent Campylobacter jejuni and Hemophilus influenzae infections, is likely the predominant pathogenic mechanism, but the roles of other biological factors remain to be established. Recent studies have demonstrated the presence of neuromuscular transmission defects in association with anti-GQ1b IgG antibody, both in vitro and in vivo. Collective findings from clinical, radiological, immunological, and electrophysiological techniques have helped to define MFS, GBS, and BBE as major disorders within the proposed spectrum of anti-GQ1b IgG antibody syndrome.

Treatment for Fisher syndrome, Bickerstaff's brainstem encephalitis and related disorders

BACKGROUND

Fisher syndrome is one of the regional variants of Guillain-Barré syndrome, characterised by impairment of eye movements (ophthalmoplegia), incoordination (ataxia) and loss of tendon reflexes (areflexia). It can occur in more limited forms, and may overlap with Guillain-Barré syndrome. A further variant is associated with upper motor neuron signs and disturbance of consciousness (Bickerstaff's brainstem encephalitis). All of these variants are associated with anti-GQ1b IgG antibodies. Intravenous immunoglobulin (IVIg) and plasma exchange are often used as treatments in this patient group. This review was undertaken to systematically assess any available randomised controlled data on acute immunomodulatory therapies in Fisher Syndrome or its variants.

OBJECTIVES

To provide the best available evidence from randomised controlled trials on the role of acute immunomodulatory therapy in the treatment of Fisher Syndrome and related disorders.

SEARCH STRATEGY

We searched the Cochrane Neuromuscular Disease Trials register (March 2004), MEDLINE (from January 1966 to November 2004), EMBASE (from January 1980 to November 2004), CINAHL (from January 1982 to November 2004) and LILACS (from January 1982 to November 2004) for randomised controlled trials, quasi-randomised trials, historically controlled studies and trials with concurrent controls. We adapted this strategy to search MEDLINE from 1966 and EMBASE from 1980 for comparative cohort studies, case-control studies and case series.

SELECTION CRITERIA

All randomised and quasi-randomised controlled clinical trials (in which allocation was not random but was intended to be unbiased, e.g. alternate allocation, and non-randomised controlled studies were to have been selected. Since no such clinical trials were discovered, all retrospective case series containing five or more patients were assessed and summarised in the discussion section.

DATA COLLECTION AND ANALYSIS

All studies of Fisher Syndrome and its clinical variants were scrutinised for data on patients treated with any form of acute immunotherapy. Information on the outcome was then collated and summarised.

MAIN RESULTS

We found no randomised or non-randomised prospective controlled trials of immunotherapy in Fisher Syndrome or related disorders. We summarised the results of retrospective series containing five or more patients in the discussion section.

AUTHORS' CONCLUSIONS

There are no randomised controlled trials of immunomodulatory therapy in Fisher Syndrome or related disorders on which to base practice.

Antiglycolipid antibodies in Guillain-Barré syndrome and related diseases: Review of clinical features and antibody specificities

Guillain-Barré syndrome (GBS) is an acute inflammatory polyradiculoneuropathy that usually develops following a respiratory or intestinal infection. Although the pathogenic mechanisms of GBS have not been fully established, both humoral and cell-mediated immune factors have been shown to contribute to the disease process. Several antiglycosphingolipid (anti-GSL) antibodies have been found in the sera of patients with GBS or related diseases. Measurements of these antibody titers are very important in the diagnosis of GBS and in evaluating the effectiveness of treatments in clinical trials. The most common treatment strategies for these disorders involve plasmapheresis and the use of steroids for reducing anti-GSL antibody titers to ameliorate patients' clinical symptoms. Administration of intravenous immunoglobulin may also be beneficial in the treatment of neuropathies by suppressing the immune-mediated processes that are directed against antigenic targets in myelin and axons. In certain demyelinating neuropathies, the destruction or malfunctioning of the blood-nerve barrier, which results in the leakage of circulating antibodies into the peripheral nerve parenchyma, has been considered to be an initial step in development of the disease process. In addition, anti-GSL antibodies, such as anti-GM1, may cause nerve dysfunction and injury by interfering with the ion channel function at the nodes of Ranvier, where carbohydrate epitopes of glycoconjugates are located. These malfunctions thus contribute to the pathogenic mechanisms of certain demyelinating neuropathies.

Clinical correlates of serum anti-GT1a IgG antibodies

Patients with the pharyngeal-cervical-brachial variant (PCB) of Guillain-Barré syndrome (GBS) have anti-GT1a IgG with or without GQ1b reactivity, whereas those with Fisher syndrome (FS) or Bickerstaff's brainstem encephalitis (BBE) have anti-GQ1b IgG antibodies which cross-react with GT1a. The nosological relationship between these conditions has yet to be established. To investigate the relationships between each manifestation and between clinical features and the coexistence of anti-GQ1b IgG, we reviewed neurological signs present during illnesses of 140 patients who had anti-GT1a IgG. Based on our criteria, FS was diagnosed for 64 (46%) patients, GBS for 22 (16%), BBE for 14 (10%), and PCB for 6 (4%). Overlapping conditions were diagnosed for some patients: FS and GBS (5%), PCB and FS (5%), BBE and GBS (4%), and PCB and BBE (1%). Patients who initially had bulbar palsy developed not only PCB but FS or BBE. The population of anti-GT1a-positive patients frequently had ophthalmoplegia, ataxia, and areflexia, whereas the subpopulation who had anti-GT1a IgG without GQ1b reactivity frequently had preceding diarrhea as well as oropharyngeal, neck, and limb weakness. Patients with anti-GT1a IgG presented a variety of clinical conditions, indicative of a continuous clinical spectrum. A major part of this clinical variation was due to the coexistence of anti-GQ1b IgG. The presence of a common autoantibody (anti-GT1a IgG) and overlapping illnesses suggests that PCB is closely related not only to GBS but to FS and BBE as well.

Bickerstaff's brainstem encephalitis: clinical features of 62 cases and a subgroup associated with Guillain-Barré syndrome

Bickerstaff reported eight patients who, in addition to acute ophthalmoplegia and ataxia, showed drowsiness, extensor plantar responses or hemisensory loss. This condition has been named Bickerstaff's brainstem encephalitis (BBE). One patient had gross flaccid weakness in the four limbs. Presumably because of the rarity of this disorder, there has been no reported study on a large number of patients with BBE. To clarify its clinical features, we reviewed detailed clinical profiles and laboratory findings for 62 cases of BBE diagnosed by the strict criteria of progressive, relatively symmetrical external ophthalmoplegia and ataxia by 4 weeks, and disturbance of consciousness or hyperreflexia. Ninety-two per cent of the patients involved had had an antecedent illness. Besides ophthalmoplegia and ataxia, disturbance of consciousness was frequent (74%), and facial diplegia (45%), Babinski's sign (40%) and pupillary abnormality and bulbar palsy (34%) were present. Almost all the patients had a monophasic remitting course and generally a good outcome. Serum anti-GQ1b IgG antibody was positive in 66%, and MRI showed brain abnormality in 30% of the patients. Another striking feature was the association with flaccid symmetrical tetraparesis, seen in 60% of the patients. An autopsy study of a BBE patient clearly showed the presence of definite inflammatory changes in the brainstem: there was perivascular lymphocytic infiltration with oedema and glial nodules. Electrodiagnostic study results suggested peripheral motor axonal degeneration. Limb weakness in the BBE cases studied was considered the result of overlap with the axonal subtype of Guillain-Barré syndrome. These findings confirm that BBE constitutes a clinical entity and provide additional clinical and laboratory features of BBE. A considerable number of BBE patients have associated axonal Guillain-Barré syndrome, indicative that the two disorders are closely related and form a continuous spectrum.

Axonal pharyngeal-cervical-brachial variant of Guillain-Barré syndrome without Anti-GT1a IgG antibody

We report two cases of pharyngeal-cervical-brachial (PCB) variant of Guillain-Barré syndrome (GBS). The patients developed dysphagia and weakness of the neck and arms subsequent to Campylobacter jejuni infection. Oropharyngeal palsy recovered poorly. Electrophysiological findings demonstrated axonal conduction failure. Anti-GD1a immunoglobulin G (IgG) antibody was detected in one case, and anti-GM1b IgG antibody in another. Anti-GT1a IgG and immunoglobulin M (IgM) antibodies were negative in both cases. The current cases suggest that the PCB and axonal variants of GBS form a continuous spectrum from the viewpoint of electrophysiological studies as well as antiganglioside serology.

Diagnosis, pathogenesis and treatment of Miller Fisher syndrome and related disorders: clinical significance of antiGQ1b IgG antibody

Miller Fisher syndrome is a variant of Guillain-Barré syndrome, characterized by ophthalmoplegia, ataxia and areflexia. The antiGQ1b immunoglobulin G antibody is a specific marker of Miller Fisher syndrome and related disorders, such as Guillain-Barré syndrome with ophthalmoplegia, atypical Miller Fisher syndrome characterized by acute ophthalmoplegia or acute ataxia and Bickerstaff's brainstem encephalitis. The antiGQ1b immunoglobulin G antibody may play some important roles in the pathogenesis of Miller Fisher syndrome and related disorders. Possible mechanisms are discussed. Molecular mimicry between an infectious agent of the antecedent infection and the ganglioside may be a mechanism of the antibody production. Plasmapheresis or intravenous immunoglobulin therapy may be warranted for Miller Fisher syndrome and Bickerstaff's brainstem encephalitis, as well as Guillain-Barré syndrome with ophthalmoplegia.

Miller Fisher syndrome and plasmapheresis

Treatment for Miller Fisher syndrome (MFS) is controversial, and even the natural history and prognosis are not fully understood. We retrospectively reviewed our cases of MFS for the last 3 years. The analysis of 4 MFS cases revealed that we had performed plasmapheresis or additional immunotherapy to each of 4 patients, and their symptoms resolved for up to 50 days after the onset (ataxia improved 20-35 days and ophthalmoplegia for 25-50 days) except for 1 patient, and that Guillain-Barré syndrome had been diagnosed in 1 patient who had developed profound muscle weakness. We also discovered that MFS patients had a deviated T-helper Type-1 (Th1)/T-helper Type-2 (Th2) polarization and that plasmapheresis can shift Th2-dominant status to Th1-dominant status in patients with MFS. Although plasmapheresis may remove humoral factors, including anti-GQ1b, and may induce a shift of the Th1/Th2 cytokine-producing cell balance in peripheral blood, the therapeutic rationale has not yet been established. Therefore, controlled clinical trials are required to show whether plasmapheresis leads to earlier recovery with fewer neurologic deficits in patients with MFS.

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.

Acute ophthalmoparesis (without ataxia) associated with anti-GQ1b IgG antibody: clinical features

OBJECTIVE

To examine the clinical features of acute ophthalmoparesis (AO) (without ataxia) associated with anti-GQ1b immunoglobulin G (IgG) antibody.

DESIGN

Retrospective observational case series.

PARTICIPANTS

Twenty-one subjects with AO (without ataxia) who had anti-GQ1b IgG.

METHODS

Clinical features of 21 subjects with AO were analyzed.

RESULTS

Seventeen had symptoms of antecedent infection. Gaze limitation was bilateral in 16 subjects and unilateral in five, indicative that laterality does not always negate AO. Nine subjects showed abducens paresis, and two limitation of abduction and adduction. Eight, who initially had bilateral abducens palsy, subsequently had impairment of adduction and vertical movement. These showed that bilateral abducens palsy followed by oculomotor nerve involvement is characteristic of AO. Muscle stretch reflexes were normal in nine subjects, hypoactive in eight, absent in three, and brisk in one. Distal paresthesias were present in seven subjects. Acellular cerebrospinal fluid (CSF) associated with raised protein concentration was detected in three.

CONCLUSIONS

Antecedent infectious symptoms, characteristic limitation of ocular movement, areflexia, distal paresthesias, and CSF albuminocytologic dissociation are useful markers for diagnosing AO as well as anti-GQ1b IgG. AO can be considered a mild form of Miller Fisher syndrome or a regional variant of Guillain-Barré syndrome.

Anti-GQ1b IgG antibody syndrome: clinical and immunological range

OBJECTIVES

To clarify the nosological relation among Miller Fisher syndrome (MFS), Guillain-Barré syndrome (GBS) with ophthalmoplegia, Bickerstaff's brain stem encephalitis (BBE), and acute ophthalmoparesis without ataxia. Serum samples from patients with each condition often have anti-GQ1b IgG antibody.

METHODS

Information on antecedent illness, initial symptoms, neurological signs during the illness, and CSF findings were reviewed in 194 patients with anti-GQ1b IgG. It was determined whether overlapping MFS and GBS (MFS/GBS), as well as overlapping BBE and GBS (BBE/GBS), is explained by the combined action of anti-GQ1b IgG and anti-GM1 or anti-GD1a IgG, serological markers of GBS.

RESULTS

Based on the diagnostic criteria, all the patients with acute ophthalmoparesis, MFS, MFS/GBS, BBE/GBS, and BBE had external ophthalmoplegia; all the patients with MFS, MFS/GBS, or GBS had hyporeflexia or areflexia; and all those with MFS and BBE showed ataxia. Tendon reflexes were decreased or absent in 91% of those with BBE/GBS, 67% of those with BBE, and 53% of those with acute ophthalmoparesis. Ataxia was present in 68% of the patients with MFS/GBS and 45% of those with BBE/GBS. Antecedent illness caused by upper respiratory tract infection had occurred in 60% to 80% of these patients, and CSF albuminocytological dissociation in 25% to 75%. Anti-GM1 or anti-GD1a IgG was present in 50% of those with GBS, 35% of those with MFS/GBS, 27% of those with BBE/GBS, 16% of those with MFS, and 8% of those with BBE.

CONCLUSIONS

These findings together with the common autoantibody (anti-GQ1b IgG) suggest that a common autoimmune mechanism functions in the pathogenesis of these illnesses. In a larger study, it was confirmed clinically that MFS, GBS, BBE, and acute ophthalmoparesis are closely related, forming a continuous range. This is supported by the immunological findings. The term "anti-GQ1b IgG antibody syndrome" is not intended to be used as a clinical diagnosis, but recognition of this syndrome is useful for understanding the aetiological relation among the various illnesses and for introducing the established treatments of GBS for use with other conditions.

Extracorporeal adsorption as a new approach to treatment of botulism

Botulism is a paralytic disease caused by a toxin produced by the bacterium Clostridium botulinum. Outbreaks of the illness take place with a mortality rate of 10%, and the potential terrorist use of the toxin has become a serious concern. The current treatment includes administration of antitoxin, which can cause serious allergic reactions. Recently, we have successfully treated a 64 year old woman with the illness with IMMUSORBA TR350 (Asahi Medical, Tokyo, Japan), an extracorporeal adsorptive column containing polyvinylalcohol-tryptophan as an adsorptive agent, which has been widely used in Japan to treat myasthenia gravis and Guillain-Barre syndrome. Initially, the patient developed ocular muscle weakness and a variant of the Guillain-Barre syndrome was suspected. After extracorporeal treatment, her neurologic symptoms remarkably improved. After a series of treatments, botulinum toxin type B was isolated in the food she had eaten, establishing the diagnosis. An in vitro study revealed that the adsorptive column removed botulinum toxin to a significant extent. Our recent findings suggest that treatment with the adsorptive column TR350 can be a feasible option for botulism, which is a rare but potentially lethal disease.

Extracorporeal antibody elimination in neuroimmunological diseases

Extracorporeal procedures for the elimination of autoantibodies are an important therapeutic option in various neuroimmunological diseases, especially those with neuromuscular involvement. Recent advances with the development of selective apheresis methods have given extracorporeal therapeutic procedures a new perspective. In this article, we review the therapeutic use of plasma exchange and immunoadsorption therapy in different neuroimmunological diseases.

Elevated bradykinin and decreased carboxypeptidase R as a cause of hypotension during tryptophan column immunoabsorption therapy

Tryptophan column immunoabsorption therapy is beneficial to the patient with a neuroimmunological disease, but some complications have been attributed to this treatment. There have been some instances of an abrupt shock state along with severe decreases in blood pressure. In regards to this shock state, it has been reported that plasma bradykinin levels increase during tryptophan column immunoabsorption therapy. In this study, we examined the correlation between plasma bradykinin levels and either blood pressure or the levels of its degrading enzymes, angiotensin converting enzyme (ACE) and carboxypeptidase R (CPR) in 6 patients. Increased concentrations of bradykinin were present in the latter half of the therapeutic interval, and plasma bradykinin levels were found to be inversely correlated to CPR activity. The decreased CPR level could augment the activities of bradykinin. We speculate that bradykinin could be responsible for the hypotension occurring in patients during tryptophan column immunoabsorption therapy and that the metabolism of bradykinin could be caused by the decreased activity of CPR.

Application of bioaffinity technology in therapeutic extracorporeal plasmapheresis and large-scale fractionation of human plasma

This paper describes the increasingly unique and powerful role that affinity chromatography is occupying both as a tool for the treatment of extracorporeal plasma exchange (to discard biological compounds with noxious metabolic or immunologic effects in patients) and as a purification tool in the production of therapeutic plasma protein derivatives. Management of both applications requires careful monitoring of the parameters applied to the plasma material, to avoid immunological stimulation or activation of the coagulation cascade. Examples of direct current applications of affinity ligands in therapeutic removal and industrial production of plasma compounds are presented.

Immusorba TR and Immusorba PH: basics of design and features of functions

Immusorba was reported by Yamazaki et al. to be the world's first practical immunoadsorbent in 1982. Since then, this immunoadsorbent has accumulated an abundance of clinical achievements. Immusorba has such unique functions that it is used in treating various diseases and holds possibilities for application to more diseases. Immusorba was designed as an artificial receptor for rheumatoid factor (RF) based on structural analysis of heat-denaturated globulin. Subsequently, new substances that it can adsorb have been found as seen in reports on the adsorption performance of Immusorba to anti-acetylcholine receptor antibodies (anti-AChR Abs) and antiganglioside antibodies. Along with this, Immusorba has been used in treating a wide range of diseases. The greatest characteristic of Immusorba is that its adsorption capability is selective rather than specific, making it effective against a great number of diseases.

Fisher syndrome associated with IgG anti-GQ1b antibody following infection by a specific serotype of Campylobacter jejuni

OBJECTIVE

The purpose of the study was to describe clinical and serologic features of Fisher syndrome associated with IgG anti-GQ1b ganglioside antibody following Campylobacter jejuni enteritis.

DESIGN

A clinical trial.

PARTICIPANTS

Four consecutive patients with Fisher syndrome were studied.

INTERVENTION

Samples of sera from four patients were tested for reactivity to GQ1b ganglioside by enzyme-linked immunosorbent assay (ELISA). Campylobacter jejuni strains isolated from samples of stool from three patients were serotyped by the method of Penner and Hennessy and that of Lior.

MAIN OUTCOME MEASURES

Serum IgG anti-GQ1b antibody titer and serotypes of C. jejuni.

RESULTS

Diplopia occurred 8 to 14 days after the onset of diarrhea. Campylobacter jejuni was isolated from samples of stool from all of the patients. ELISA revealed a high serum IgG anti-GQ1b antibody titer for all four patients. Two patients had high serum titers of other antiganglioside antibodies frequently related to Guillain-Barré syndrome. These two patients developed limb weakness following the onset of ophthalmoplegia. The C. jejuni serotype was Penner's serotype 2 for all three of the patients tested.

CONCLUSIONS

These findings suggest that C. jejuni, especially Penner's serotype 2, enteritis could trigger development of Fisher syndrome associated with IgG anti-GQ1b antibody.

Immunoadsorption therapy in Guillain-Barré syndrome

A 12-year-old boy rapidly developed Guillain-Barré syndrome (GBS) after Campylobacter jejuni enteritis. Electrophysiologic studies suggested that demyelination was dominant, and serum anti-C. jejuni and both IgG and IgM anti-GM1 antibodies were significantly elevated. The patient was treated three times with immunoadsorption therapy using a tryptophan-immobilized column. The volume of treated plasma in each session was about 2 L. His blood pressure was maintained within normal range with the use of 5% albumin preparations and etilefrine hydrochloride. His clinical and electrophysiologic findings began to recover shortly after therapy, with a decrease in the levels of serum IgG and IgM anti-GM1 antibodies. This immunoadsorption therapy should be considered for anti-GM1 antibody-associated GBS.

The role of glycosphingolipids in neurological disorders. Mechanisms of immune action

Specific criteria that are required for understanding the significance of glycosphingolipid (GSL) antibodies, as well as mechanisms that may underlie the immunopathogenesis of these disorders, are proposed. These criteria are illustrated by describing the role of a unique family of acidic GSLs, the sulfated glucuronosyl glycolipids (SGGLs), in the pathogenic mechanisms of peripheral neuropathy with IgM paraproteinemia. High anti-SGGL antibody titers are detected in patients suffering from this disorder. It is demonstrated that SGGLs, which possess a common carbohydrate epitope with myelin-associated glycoprotein (MAG), several low-molecular-weight glycoproteins in the PNS, and a number of cell adhesion molecules, are potential target antigens for the neuropathy. Evidence is provided that sensitization of laboratory animals with pure SGGLs elicits experimental peripheral neuropathies that exhibit remarkable similarities with respect to antibody specificity, and electrophysiological and pathological features to the human conditions. By intraneural injection of antibodies into the sciatic nerve of rats, it is demonstrated that pathological changes consisting of demyelination and axonal degeneration are mediated by an antibody- and complement-dependent process. To elucidate the mechanisms of antibody penetration from circulation into the endoneurial space, it is further shown that brain microvascular endothelial cells express SGGLs. Moreover it has been found that inflammatory cytokines are capable of upregulating the expression of SGGLs on the endothelial cell surface, resulting in a greater attachment of leukocytes. This latter observation suggests that SGGLs may also participate in cell-mediated responses in certain inflammatory neurological disorders.

Ability to remove immunoglobulins and anti-ganglioside antibodies by plasma exchange, double-filtration plasmapheresis and immunoadsorption

In Japan, patients with Guillain-Barré (GBS) and Fisher's (FS) syndromes often receive plasma exchange (PE), double-filtration plasmapheresis (DFPP), or immunoadsorption (IA). To determine whether DFPP and IA are as effective as PE, we compared their abilities to remove immunoglobulins and anti-ganglioside antibodies. Plasma samples were obtained from 55 GBS patients and 53 FS patients, before and after each session of the treatments. PE decreased the IgG concentration more than DFPP did, its abilities to remove anti-ganglioside IgG antibodies in PE markedly being superior to the abilities of the other plasmaphereses. IA on a tryptophan-immobilized column adsorbed anti-ganglioside IgG antibodies more effectively than IA on other affinity columns.

Clinical correlate and fine specificity of anti-GQ1b antibodies in peripheral neuropathy

We studied the frequency, fine specificity and clinical correlate of anti-GQ1b IgG and IgM antibodies in 216 patients with neuropathy including three with Miller Fisher syndrome (MFS), 73 with Guillain-Barré syndrome (GBS), 99 with neuropathy associated with IgM monoclonal gammopathy (PN+IgM) and 41 with other neuropathies, and compared the data with 92 disease or normal controls. We found high (>1/100) anti-GQ1b IgG titers in all three MFS patients and in two GBS patients (2.7%) with ophthalmoplegia and ataxia, while high anti-GQ1b IgM were only found in two patients with a chronic demyelinating sensorimotor neuropathy associated with IgMkappa monoclonal gammopathy (2%). By overlay HPTLC, IgG antibodies in MFS and GBS either selectively reacted with GQ1b or also bound to GD3, and less intensely to GD1b, while IgM antibodies from both patients with PN+IgM also strongly reacted with GD1b and, in one, with GD3 and GT1b. The constant association of anti-GQ1b antibodies with dysimmune neuropathies and the correlation between their isotype, fine specificity and clinical presentation, support a possible pathogenetic link between these antibodies and the neuropathy.

Can immunoadsorption plasmapheresis be used as the first choice therapy for neuroimmunological disorders?

The subjects were 31 patients in whom immunoadsorption plasmapheresis (IAPP) was performed as the first choice therapy for primary or recurrent neuroimmunological disorders. The clinical manifestations before and after IAPP and the use of corticosteroids were investigated in the present study. IAPP was clinically effective in all patients. The corticosteroids (CSs) administration was begun or CSs were increased after completion of IAPP in 11 patients. IAPP was performed as the first choice therapy, and favorable results were obtained in patients with Guillain-Barré syndrome and Miller-Fisher syndrome. IAPP alone was also effective in a patient with lupoid sclerosis. When IAPP was used alone in 2 patients with chronic inflammatory demyelinating polyradiculoneuropathy, it completely eliminated the clinical manifestations, but the symptoms recurred about 2 months later. Therefore, although IAPP could be performed as the first choice therapy for many neuroimmunological disorders, subsequent therapies should be carefully investigated.

Comparison of the adsorption ability between tryptophan and modified tryptophan columns

Immunoadsorption therapy (IAT) using the tryptophan column (TR:TR-350, Asahi Medical Co., Tokyo, Japan) is used for patients with Guillain-Barré syndrome or Fisher's syndrome. Recently, a modified tryptophan column (modified TR:TR-350S, Asahi) was developed to reduce adsorption of fibrinogens. However, it is not clear whether the new column can effectively adsorb the antiganglioside antibodies. We treated 2 patients with Guillain-Barré syndrome, 1 patient with Fisher's syndrome, and 1 patient with Bickerstaff's brainstem encephalitis by IAT using the TR and the modified TR. Samples were taken from the inlet and outlet of the affinity column. We compared the adsorption ability of antiganglioside antibodies between the TR and modified TR. The modified TR adsorbed antiganglioside antibodies less effectively than the TR. No significant bleeding was observed in the patients during each session. Furthermore, results of the clinical study were confirmed by batchwise adsorption test. We propose that the modified TR should not be used for treating patients with Guillain-Barré syndrome and related disorders.

Antibodies to GM1 and Gal(beta 1-3)GalNAc at the nodes of Ranvier in human and experimental autoimmune neuropathy

Autoantibodies to Gal(beta 1-3)GalNAc epitopes on glycolipids and glycoproteins are associated with motor neuron disease and motor or sensorimotor neuropathy. These epitopes are ubiquitously distributed on cell surfaces. In the nervous system they are present on axons and myelin, specifically also at the nodes of Ranvier. Binding of GM1 antibodies to the nodal area may contribute to disease development in some of these conditions.