Disorders of the Cauda Equina

PURPOSE OF REVIEW

Conditions that affect the cauda equina are a diverse group of disorders that require timely recognition and management. This article reviews cauda equina anatomy, the diagnostic approach to disorders of the cauda equina, features of cauda equina syndrome, and diskogenic and nondiskogenic disorders of the cauda equina.

RECENT FINDINGS

Establishing clinical criteria for cauda equina syndrome has been a focus of a number of reviews, although the clinician must maintain a low threshold for emergent imaging in cases of suspected cauda equina syndrome because of the suboptimal reliability of various signs and symptoms in identifying this condition clinically. The timing of surgical intervention for compressive causes of cauda equina dysfunction remains a point of contention, although urgent decompression remains standard practice. A recent review that focused on outcomes in patients with cauda equina compression who underwent surgical decompression identified significant residual deficits in patients despite appropriate and timely intervention. Autoimmune conditions targeting the cauda equina have been increasingly recognized, including chronic immune sensory polyradiculopathy and chronic immune sensorimotor polyradiculopathy.

SUMMARY

Disorders that affect the cauda equina require thoughtful and timely clinical examination and diagnostic testing to establish a definitive cause and an appropriate treatment approach.

Immunological profiles determine neurological involvement in Sjögren's syndrome

BACKGROUND

Up to 68% of patients with primary Sjögren's syndrome (pSS) undergo neurological complications, and evidence for distinct immunological subgroups is emerging. We sought to determine systemic and immunological profiles associated with neurological manifestations.

METHODS

420 patients fulfilling the 2002 American-European pSS criteria were retrospectively analyzed. Neurological manifestations were diagnosed through clinical, biological, electrophysiological, and imaging findings. Biographical, clinical, and laboratory data were compared.

RESULTS

Within 93 (22%) patients with neurological manifestations, peripheral and central nervous systems were involved in 66% and 44%, respectively. Raynaud's phenomenon, cutaneous vasculitis, renal involvement, and cryoglobulinemia were associated with sensorimotor neuropathy and mononeuritis multiplex (p<0.05). Conversely, pure sensory neuropathy occurred without extraglandular manifestation, and without anti-Ro/SSA antibodies (p<0.05). All neurological manifestations were associated with increased use of corticosteroids and immunosuppressive drugs (p<0.05).

CONCLUSIONS

In pSS, patients with sensorimotor neuropathies and pure sensory neuropathies have distinct extraglandular and immunological profiles.

Chronic inflammatory demyelinating polyradiculoneuropathy presenting as cauda equina syndrome in a diabetic

Chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) may occur in association with diabetes mellitus (DM). We report a case of a poorly controlled diabetic patient who presented with rapid onset of bilateral lower extremity weakness and sensory loss associated with sacral and posterior thigh paresthesias and urinary and bowel incontinence, indicative of cauda equina syndrome (CES). Subsequent evaluation was consistent with CIDP. Monthly infusions with intravenous immunoglobulins (IVIg) with strict glycemic control using insulin resulted in remarkable clinical and electrophysiological recovery. This case report describes a rare presentation of CIDP and emphasizes the importance of early utility of electrodiagnostic (EDX) studies in the clinical evaluation of diabetic patients presenting with rapidly progressive lower extremity weakness and sensory loss associated with diminished reflexes.

Paraproteinemic neuropathy

Paraproteinemia frequently is associated with peripheral neuropathy. The clinical manifestations can be protean owing to the potential for multiple organ involvement. A methodical diagnostic approach to patients who have a plasma cell dyscrasia and neuropathy is necessary to ensure the appropriate detection of more widespread systemic involvement.

[Problems of differential diagnosis in tick-borne encephalitis-induced polyradiculitis]

In about 10% of cases, tick-borne encephalitis (TBE) presents with additional myeloradiculitic features mimicking acute poliomyelitis, which can rarely appear as the sole symptom. We report on a 59-year-old man infected with TBE in Thuringia,Germany, who developed polyradiculitis with rapidly progressive, predominantly proximal tetraparesis and respiratory failure. We discuss the differential diagnosis and the epidemiological relevance in conjunction with a second typical case of TBE acquired in the same region and time period.

Neurophysiologic changes in lumbar nerve root inflammation in the rat after treatment with cytokine inhibitors. Evidence for a role of interleukin-1

STUDY DESIGN

The present study was designed to evaluate the effect of cytokine inhibitors in experimental allergic radiculitis.

OBJECTIVE

Evaluation of the effect of cytokine inhibitors in experimental allergic radiculitis.

SUMMARY OF BACKGROUND DATA

A number of cytokines are known to be involved in hyperalgesia and may play a role in radiculitis. Corticosteroids and other cytokine inhibitors antagonize their effects.

METHODS

Experimental allergic radiculitis was induced in rats by injection of bovine myelin from the peripheral nervous system. The sham group subsequently received saline injections; the treatment groups received either prednisolone or interleukin-1 receptor antagonist. Treatment effect was assessed on the basis of motor performance and neurophysiologic parameters.

RESULTS

Treatment ameliorated the symptoms of experimental allergic radiculitis. Prednisolone appeared to be somewhat more effective than interleukin-1 receptor antagonist.

CONCLUSIONS

Because interleukin-1 receptor antagonist specifically blocks the effects of interleukin-1 at its receptors, the present results imply that interleukin-1 is a causal factor in the model of experimental radiculitis used. Its specificity and apparent lack of side effects make interleukin-1 receptor antagonist an attractive candidate treatment for the human disease.

Contrast-enhanced magnetic resonance imaging of the lumbosacral roots in the dysimmune inflammatory polyneuropathies

The diagnosis of acute Guillain-Barré syndrome and chronic inflammatory demyelinating polyradiculoneuropathy is based on clinical characteristics, abnormalities on nerve conduction studies, and nerve biopsy specimens indicating demyelination. Inflammation and edema are also common findings in nerve specimens. Immunotherapy is helpful in these dysimmune conditions. Occasionally the diagnosis is difficult to make, particularly when electrophysiological testing or nerve biopsy findings are not characteristic. The authors found contrast enhancement of lumbosacral roots in patients with chronic inflammatory demyelinating polyradiculoneuropathy and Guillain-Barré syndrome, but not in those with other demyelinating neuropathies. Contrast-enhanced magnetic resonance imaging could be a useful tool in the diagnosis of the dysimmune inflammatory neuropathies.

Acute radiculomyelitis after antitetanus vaccination

Active or passive immunisation with vaccines or sera can cause lesions of immunomediated pathogenesis involving both the central (CNS) and the peripheral nervous system (PNS). Although very rare, the neurological complications described during antitetanus vaccinations almost exclusively affect the PNS, those affecting the CNS being even more rare. The authors report a case of transverse myelitis with a radicular component, which arose acutely following the administration of tetanus toxoid and had a partially favourable course.

[Immunomodulator therapy of chronic inflammatory demyelinating polyradiculoneuropathy]

A group of 6 patients with chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) was treated with prednisone, azathioprine, plasma exchange and/or intravenous immunoglobulin. Three of the six patients improved during treatment with prednisone and two patients with severe CIDP both showed a remarkable therapeutic response to treatment with intravenous immunoglobulin.

Immunoglobulin abnormalities in cerebrospinal fluid and blood over the course of lymphocytic meningoradiculitis (Bannwarth's syndrome)

The conditions of 5 patients with untreated lymphocytic meningoradiculitis (Bannwarth's syndrome, probably equivalent to Lyme disease) with serologically confirmed infection resulting from Borrelia spirochetes were followed with repetitive lumbar punctures up to 221 days after the onset of symptoms. Using a protein A plaque assay, high numbers of IgG-, IgM-, and IgA-producing cells were found in the cerebrospinal fluid (CSF), whereas there were mostly normal numbers of immunoglobulin-producing cells in peripheral blood. A markedly increased CSF IgM index and an elevated IgG index were observed in all patients during the early phase, reflecting production of these immunoglobulins within the central nervous system. All patients had oligoclonal IgG bands in the CSF that persisted during follow-up; in the 2 patients tested, the bands contained Borrelia antibodies. Most serum immunoglobulin concentrations were normal and in only 1 patient was it possible to detect in serum some of the oligoclonal IgG bands present in CSF. Declining numbers of CSF cells producing immunoglobulin and decreasing immunoglobulin index values were observed during follow-up, but 3 patients had an elevated CSF IgM index in the presence of normal IgG and IgA indices when examined during the later phases of disease. An intense and prolonged IgM response within the central nervous system seems to be a characteristic of the disease.

Serological diagnosis of erythema migrans disease and related disorders

An indirect immunofluorescence technique for the determination of antibodies against ixodid tick spirochetes is described. Differences in the reactivity between Ixodes ricinus spirochete and Ixodes dammini spirochete antigens were not observed. Cross-reacting antibodies against Treponema pallidum and Treponema phagedenis can be eliminated by quantitative absorption with T. phagedenis. Cross-reactions with leptospira were not observed by immunofluorescence. In the IgM test, false negative reactions caused by high-titered specific IgG antibodies or false positive reactions caused by rheumatoid factor occur. This can be avoided by testing the IgM fraction (19S-IgM-test) or using sera previously treated with anti-IgG serum. Significantly elevated antibody titers against ixodid tick spirochetes were observed in 45% of 44 cases with erythema migrans disease, in 72% of 29 cases of lymphocytic meningoradiculitis, in all of nine patients with acrodermatitis chronica atrophicans and in all of four investigated patients with lymphocytoma (lymphadenosis benigna cutis).

Abnormal T cell subpopulations and circulating immune complexes in the Guillain-Barré syndrome and multiple sclerosis

Immunologic studies were performed in 21 patients with multiple sclerosis (MS) and 16 with the Guillain-Barré syndrome (GBS). Levels of thymus-derived (T) cells measured by "total" and "active" rosette formation between sheep erythrocytes and peripheral blood mononuclear cells (TEt, TEa) were within normal limits in all the patients, with the exception of four GBS patients, including one who also had received chemotherapy for lymphoma and three who were receiving steroids. When lymphocytes from the 21 patients were incubated with the bone-marrow-derived (B) lymphoblastoid cell line PGLC-33H, there were, for 12 of 18 MS patients and 11 of 16 GBS patients, significant decreases in a subpopulation of peripheral blood T lymphocytes that form "PGLC rosettes" (PGR) with the PGLC-33H cells. (Peripheral blood T cells from normal individuals formed PGR with 23.9 +/- 3.8 percent of PGLC-33H cells.) Using the 125l-C1q binding assay, immune complexes were detected in the serum of 14 of 19 MS patients and 15 of 16 GBS patients. An association between increased C1q binding and decreased PGR values was found in 10 of 18 MS patients and 12 of 17 GBS patients. The results suggest that in both diseases the etiology may involve a decrease in the subset of T cells that bind to the IgM-producing cell line PGLC-33H, in association with the appearance of circulating immune complexes containing the infectious viral agent.

Cytomegalovirus complement fixation antibody in Guillain-Barré syndrome

Cytomegalovirus, measles, and adenovirus antibodies were measured in the sera of 92 Guillain-Barré patients and 120 controls. Thirty patients (33 percent) had markedly elevated levels of complement-fixing antibody to cytomegalovirus and in 21, a fourfold or more alteration in titer was demonstrated. Diagnostic falls in titer were seen in most instances and no significant elevation to the other viral agents was found. The serologic findings reported here suggest that cytomegalovirus may be a common agent involved in the pathogenesis of the Guillain-Barré syndrome.

HLA antigens in Guillain-Barré syndrome

Sixty patients with suspected lumbar herniated disk and/or canal stenosis were studied prospectively with surface coil MRI, CT, and/or myelography, and the results were compared with the surgically confirmed abnormality. Forty-eight patients had lumbar surgery at 62 levels. There were no negative explorations. Thirty-nine patients had a myelogram and CT. Thirty of the CTs were performed following the injection of metrizamide for myelography. Nine patients had a CT without intrathecal contrast material 1 to several days before the myelogram. Six patients had myelography only, and three patients had CT only. All studies were evaluated for the location and type of disease in a forced choice fashion. Independent of the surgically correlated levels, there was 86.8% agreement between the MR and CT studies in all patients at 151 levels and 87.2% agreement between MR and myelography at 218 levels. At the operative levels, there was 82.6% agreement between MR and surgical findings for both type and location of disease; 83% agreement between CT and surgical findings; and 71.8% agreement between myelography and surgical findings. There was 92.5% agreement when MR and CT were used jointly, and 89.4% agreement when CT and myelography were used jointly. The results of this study indicate that a technically adequate MR examination was equivalent to CT and myelography in the diagnosis of lumbar canal stenosis and herniated disk disease. CT and MR can be complementary studies, and surface coil MR can be viewed as an alternative to myelography.

Experimental allergic neuritis induced by a basic neuritogenic protein (P1L) of human peripheral nerve origin

Experimental allergic neuritis (EAN) in the peripheral nervous system, without involvement of the central nervous system, was produced in laboratory animals by the injection of a basic neuritogenic protein, P1L, purified from human peripheral nerves. The animals manifested a positive skin test with P1L, and their lymphocytes were found to be transformed in vitro in the presence of this protein several days before the appearance of the clinical signs. Passive transfer of the disease was performed with lymph node cells from donor guinea pigs immunized with P1L protein. EAN, the experimental model for the human disease Guillaain-Barré syndrome, was shown to be a transient disease and could be suppressed by the administration of hydrocortisone.

Cytomegalovirus as a frequent cause of Guillain-Barré syndrome

In 10 patients with Guillain-Barré syndrome a preceeding cytomegalovirus infection could be demonstrated by virus-specific IgM antibodies that were present in high titers in 9 of the 10 patients in the first serum specimen. The IgM antibodies to cytomegalovirus were detected by a sensitive "double" indirect immunofluorescence technique. In most of our cases (8 of 10) the complement-fixing antibody titers had already reached high levels on admission into a hospital, and significant titer changes were not observed. Cytomegalovirus was isolated from the urine of five patients.

[Guillain Barré- polyneuroradiculitis and Fisher-syndrome in cytomegalovirus infections (author's transl)]

In seven patients suffering from polyneuroradiculitis of the Guillain-Barré type and one case of Fisher syndrome, a cytomegalovirus infection was found. The elevation of the virus-specific IgM-antibodies was confirmed in all cases. The clinical course was severe and acute with respiratory disturbances, but complete remission occurred within 1-4 months. The complement fixing antibodies were highest during the first week of illness, so that further elevations could not be demonstrated, therefore making the IgM-antibody method of special importance. The role of cytomegalovirus infections in polyneuroradiculitis is also discussed.

Circulating immune complexes in multiple sclerosis and other neurological diseases

Circulating immune complexes were detected in 49% of sera from patients with multiple sclerosis, 45% of monosymptomatic optic neuritis, 45% of Guillain-Barré syndrome, and 15% of normal sera studied. The frequency of immune complexes in multiple-sclerosis sera was not correlated with the clinical status of the patients. Results with serial blood-samples were variable.

[Recurrent polyneuropathy with a 19-year course, associated with a benign IgG monoclonal gammapathy]

A case of recurrent polyradiculoneuritis in a 54-year-old man is described. It is exceptional because of its lengthy development over a period of 19 years and by its association with a paraprotein of the IgE type without anyother anomal. Corticotherapy had a favourable effect on the clinical symptoms but did not affect the amount of monoclonal immunoglobulin in the serum. The nosological position of this neuropathy and the type of gammapathy are discussed. An immune mechanism seems likely, but no proof of a link between the neuropathy and the gammapathy could be found.

Antibodies to Epstein-Barr virus and cytomegalovirus in Guillain-Barre syndrome

Twenty-three patients with Guillain-Barré syndrome (GBS) were investigated for serum antibody titres against Epstein-Barr virus capsid antigen (EBV-VCA), cytomegalovirus (CMV) and herpes simplex virus type 1 (HSV1). The geometric mean EBV-VCA titre was 45 in GBS, compared with 15-22 in healthy adults and 60 in sarcoidosis. Nine of the 15 GBS patients (60%) from whom multiple serum specimens were available, displayed a four-fold variation in antibody titre to EBV-VCA during the course of their disease. The geometric mean titres against CMV and HSV were also slightly higher in GBS compared with controls, but no titre variations were observed. Serial samples of both serum and cerebrospinal fluid (CSF) were available from 2 patients. Serum antibody titres against EBV were significantly higher in both during the initial phase of the disease. Serum antibody titres against CMV were also significantly elevated in 1 patient, but not until the second month after onset. The CSF antibody titres against EBV were higher in the beginning of the disease compared with the values during convalescence, but the titres observed were low. No measurable CSF antibody titres against CMV were found. The observation of varying serum antibody titres against EBV during the course of GBS can be interpreted as primary infections or as manifestations of reactivated latent virus infections. Further studies of the pathogenetic significance of this for the aetiology of the disease are warranted.

Lymphocyte transformation studies in Mycoplasma pneumoniae infections

The in vitro transformation of lymphocytes stimulated by a Mycoplasma pneumoniae preparation was measured by the uptake of 14C-thymidine. The lymphocytes from five patients with M.pneumoniae pneumonia showed a high degree of responsiveness when they were compared to the lymphocytes taken from eleven healthy control subjects who lacked M.pneumoniae antibodies. Another four patients with an acute affection of the central nervous system and serological evidence of an actual or recent M.pneumoniae infection had a lymphocyte response within the same range as that of the controls. The transformation of lymphocytes was studied at intervals for seven months after the onset of the illness in one of the patients with pneumonia. These studies showed an increasing response to a small dose of mycoplasma antigen. Lymphocyte transformation induced by other microbial antigens was studied in three pneumonia patients during and after convalescence. The first responses were low and increased more steeply than the response to M.pneumoniae. The later responses to the mycoplasmal and to the other microbial antigens increased in parallel. The usefulness of incorporating other microbial antigens in the evaluation of the patient's immune response to a relevant antigen in this type of experiment is discussed.

Optic neuritis in the Landry-Guillain-Barré-Strohl syndrome

A patient with typical Landry-Guillain-Barré-Strohl syndrome (LG-BS) developed bilateral optic neuritis. Laboratory studies showed hypersensitivity to both central and peripheral nervous tissue myelin. The occurrence of optic neuritis is presumably due to autohypersensitivity to central nervous tissue myelin. The initial lesions of the LG-BS syndrome in the peripheral nerves might have liberated sequestered antigens that cross-reacted with central nervous system myelin.

Cell-mediated immunity to neural antigens in idiopathic polyneuritis and myeloradiculitis. Clinical-immunologic classification of several autoimmune demyelinating disorders

Patients with peripheral nervous system disorders were tested for the presence of cellular hypersensitivity to peripheral and central nervous system antigens by means of the in vitro lymphocyte transformation technique. Lymphocytes sensitized to the neuritogenic peripheral nervous system P1L basic protein were found in pure polyradiculitis of the Guillain-Barré syndrome type. Lymphocytes from patients with myeloradiculitis underwent transformation by peripheral P2 basic protein and by central nervous system basic encephalitogenic protein. In cases of chronic relapsing polyneuropathy response was shown to the central nervous system basic encephalitogen and to both of the peripheral nerve basic proteins. Lymphocytes from patients with other neurologic conditions showed no response to any oth these antigens. These findings suggest that cell mediated immunity to specific basic proteins of the myelin plays a rolw in the pathogenesis of the above-mentioned demyelinating disorders and may lead to a new approach in their classification and diagnosis.

Neurologic complications with elevated antibody titer after acute hemorrhagic conjunctivitis

Nine patients with polyradiculomyeloneuropathy after acute hemorrhagic conjunctivitis (AHC) infection were studied serologically. All except one patient had neutralization titers larger than or equal to 1:16 against the prototype J670/71 strain of AHC virus in at least one of their serum samples. The development of a significant fourfold rise in antibody titer against AHC virus occurred in one of the patients who developed neurologic complications five days after the onset of AHC infection.

[Pathogenesis of neural lesions in Marek's disease. I. Allergic skin reaction against myelin of the peripheral nerves (author's transl)]

23 chickens affected with Marek's disease were tested by the allergic skin reaction for delayed hypersensitivity against myelin and myelin preparations of peripheral nerves. 19 animals proofed to be positive in the skin test, yet there was no correlation with the intensity of the nerve affections. 4 animals with severe mononuclear neural infiltrations didn't show any allergic skin reaction. It could be demonstrated that in Marek's disease lymphocytes are sensitized against components of the peripheral myelin. Thereafter, Marek's disease stands in analogy to the Guillain-Barré syndrome of man, as well as to experimental allergic neuritis.

Cellular immune response to peripheral nerve basic protein in idiopathic facial paralysis (Bell's palsy)

Lymphocytes from patients with Bell's palsy were shown to undergo significant stimulation when cultured in vitro in the presence of a purely neuritogenic basic protein (P1L) isolated from human peripheral nerve myelin. No sensitization was observed to other neural antigens, namely, another periperal nerve myelin basic protein (P2) and the central nerve myelin basic encephalitogenic protein (BE). A similar pattern of response was also demonstrated in patients with Guillain-Barré syndrome (GBS). Lymphocytes from patients suffering from other neuropathies or other diseases involving the face showed no response to any of these antigens. The specific in vitro response to P1L protein in Bell's palsy may suggest that an in vivo sensitization of lymphocytes to such self protein occurs in this condition, and that cell-mediated, probably post-infectious, autoimmune mechanisms may be an important factor in the pathogenesis of the paralysis. Thus, Bell's palsy is immunologically similar to GBS, or may even represent a mononeuritic variant of GBS. In view of these findings the administration of steroids to patients with Bell's palsy seems logical on the basis of their immunosuppressive action.

Cellular hypersensitization to peripheral nervous antigens in the Guillain-Barré syndrome

The macrophage migration inhibition factor assay was used as a specific measure of cellular hypersensitivity to peripheral nervous system antigen in a large group of Guillain-Barre patients and control subjects. Lymphocytes from 34 patients with Guillain-Barre syndrome, 33 with other peripheral nervous system disease, and 33 normal controls were assayed for production of macrophage migration inhibition factor. A mean of 101 +/- 7.2 was obtained in the control group, 70 +/- 16.3 in the Guillain-Barre syndrome group, and 96 +/- 11.3 in those with other peripheral nervous system disease. Twenty-six of the 34 patients with Guillain-Barre syndrome, two patients with myeloradiculitis, and two with Bell's palsy gave significant values. These results support the hypothesis that cellular hypersensitization to peripheral nervous system antigens is a pathogenetic factor in Guillain-Barre syndrome.

Demonstration of oligoclonal immunoglobulin G IN Guillain-Barré syndrome

Elevated concentrations in CSF of the immunoglobulins G, A, and M, when expressed as a percentage of the total protein concentration of CSF, were demonstrated during the initial phase of the course of the disease in a patient with Guillain-Barre syndrome (GBS). A slight elevation of the relative concentrations of IgG and IGM in CSF were also registered later in the course of the disease, at the time when the patient's neurological symptoms were in regression. Multiple discrete IgG bands were demonstrated by agarose electrophoresis in serum and in CSF during the first 2 weeks after onset of the neurological symptoms, and also after week 2 and still during week 12 after onset. The finding of transient oligoclonal IgG in a parient with GBS may suggest stimulation with e.g. viral antigen.

[On the behaviour of the main immunoglobulin fractions in the CSF in the course of inflammatory conditions involving the CNS (AUTHOR'S TRANSL)]

Variations of the main immunoglobulin fractions in CSF were studied in 79 children with various inflammatory processes of CNS (purulent and viral meningitis, post-infectious meningoencephalitis, polyradiculoneuritis, etc). This study was extended to a group of non-inflammatory neurological diseases. Increased values of CSF immunoglobulins (especially IgG and IgA) were found in the group of purulent meningitis and in the group of post-infectious meningoencephalitis. IgM was detected in very few cases. Generally, a correlation was observed between highest concentrations of CSF immunoglobulins and degree of meningeal inflammatory response, even if this was a component of other neurological diseases. It is suggested that the rise of CSF IgG and IgA may depend upon the CSF-blood barrier damage, as it occurs in most inflammatory diseases studied. On the contrary, a production "in situ" of CNS could explain the presence of cerebrospinal IgM.

Cellular hypersensitivity to basic myelin (P2) protein in the Guillain-Barré syndrome

Lymphocytes of 29 subjects were assayed for MIF production in response to P2 peripheral nerve protein, crude human peripheral nerve and human central nervous system Al basic myelin protein. Seven were performed in normal control subjects, 12 in Guillain-Barre patients (GB), 5 with other polyneuropathies and 5 in patients with multiple sclerosis (MS). Only GB patients with acute illness produced MIF in response to neuritogenic P2 protein and crude human nerve. Two MS patients in the acute phase of an exacerbation and one GB patient produced MIF in Response to Al protein. The results of this study demonstrate cellular hypersensitivity to a neuritogenic consituent in peripheral nervous tissue and support the concept that this may be important in the pathogenesis of GB.

[IgM immunoglobulin in cerebrospinal fluid in cases of multiple sclerosis (preliminary report)]

In cases of multiple sclerosis, central nervous system syphilis and other neurological diseases the IgM was determined in the cerebrospinal fluid by means of radial diffusion. The control group comprised patients with neurosis. It was found that IgM determinations must be done in concentrated fluid when this method is used. Raised total and percent level of IgM in the cerebrospinal fluid was observed in 8 out of 29 cases of multiple sclerosis in the acute phase of the disease.

Guillan-Barré syndrome in heroin addiction

In two cases of Guillain-Barré syndrome (acute polyneuritis) as a complication of narcotic abuse, the onset of paralysis began approximately 4 and 12 hours after self-administration of opiates intravenously. Bulbar and respiratory paralysis developed in one patient and required prolonged ventilation therapy; the other patient had peripheral muscular and unilateral facial weakness, with notable pleocytosis was present in both.

[A case of Guillain-Barré syndrome following cholera vaccination (author's transl)]

A 45-year-old woman developed bilateral ascending flaccid paralysis after cholera vaccination, 15 days after the first and 1 day after the second injection. The clinical course resulted in nearly complete paralysis of the lower limbs, paresis of the upper limbs and partial involvement of the cranial nerves. There was only slight sensory loss. The CSF revealed no pleocytosis and a protein level of 206 mg/100 ml. Recovery began 2 weeks later and was almost complete after 2 months. Immunological investigations revealed no remarkable changes.

Antimyelin antibodies in neurologic diseases. Immunofluorescent demonstration

Antimyelin binding activity was determined in patients with multiple sclerosis, amyotrophic lateral sclerosis, other neurologic diseases, and normals. There was an increase in the group mean titer of antimyelin antibodies in patients with multiple sclerosis (MS) in acute exacerbation, amyotrophic lateral sclerosis (ALS) and Guillain-Barré syndrome. A lesser degree of binding was found in normals of all ages. There was an increase in the incidence of antimyelin antibodies in the IgM class in patients with ALS and MS. The interaction between human immunoglobulins and myelin seems to be immunologically specific and has the nature of an antigen-antibody reaction.