Guillain-Barré syndrome

Prevalence, Antimicrobial Resistance, and Molecular Typing of Thermophilic Campylobacter Spp. in a Greek Poultry Slaughterhouse

Campylobacter species are one of the leading causes of foodborne disease. Poultry is a major reservoir and source of its transmission to humans. The aim of this study was to estimate the prevalence and antimicrobial resistance of Campylobacter spp. isolated from chicken carcasses, the environment, and processing equipment of a poultry slaughterhouse in Greece, to identify the dominant Campylobacter species and to determine if there are clonal relationships among the isolates. Fifty poultry samples and 25 environmental samples were examined using microbial cultures and PCR. Forty-nine of 50 poultry samples (98%) were found to be positive for Campylobacter spp. The environment of the slaughterhouse was also found to be significantly contaminated with Campylobacter spp. Thirty-seven isolates were found to be susceptible to all antimicrobials tested (56.1%) and 29 isolates showed resistance to at least two of the antimicrobials tested (43.9%). We observed 24 different PFGE-types among the 53 isolates with 14 of them isolated only once, while five PFGE-types were represented by two isolates. The remaining 29 isolates were represented by five PFGE-types each consisting of three to 12 isolates. Regarding the relationship of the PFGE types and corresponding resistance profiles, all strains of each PFGE-type shared the same antimicrobial resistance profile. This study reports evidence for Campylobacter spp. cross-contamination among broiler carcasses in a Greek slaughterhouse.

Zika Virus Pathogenesis: From Early Case Reports to Epidemics

For the first 60 years following its isolation, Zika virus (ZIKV) remained a relatively poorly described member of the Flaviviridae family. However, since 2007, it has caused a series of increasingly severe outbreaks and is now associated with neurological symptoms such as Guillain-Barré syndrome and congenital Zika syndrome (CZS). A number of reports have improved our understanding of rare complications that may be associated with ZIKV infection in adults, the areas of the body to which it spreads, and viral persistence in various tissues. Likewise, studies on the effect of ZIKV infection during pregnancy have identified risk factors for CZS and the impact this syndrome has on early childhood. Understanding these outcomes and the factors that drive ZIKV pathogenesis are key to developing vaccination and therapeutic approaches to avoid these severe and potentially debilitating symptoms.

Surveillance for Guillain-Barré syndrome after 2015-2016 and 2016-2017 influenza vaccination of Medicare beneficiaries

BACKGROUND

Guillain-Barré syndrome (GBS) is a serious acute demyelinating disease, an increased risk of which was found after the 1976 swine flu vaccinations. The U.S. Food and Drug Administration, in collaboration with the Centers for Medicare & Medicaid Services, has been conducting active surveillance for GBS after influenza vaccinations of Medicare Fee-For-Service beneficiaries since 2009.

METHODS

We conducted active surveillance for GBS claims in the 2015-2016 and 2016-2017 influenza seasons using the Updating Sequential Probability Ratio Test (USPRT) to monitor for signals of GBS risk. We performed self-controlled risk interval (SCRI) analyses at the end of both seasons, including chart confirmation in the 2015-2016 season, to estimate the odds ratio of GBS risk. We used 1-42 and 8-21 days post-vaccination as primary and secondary risk windows, respectively, and 43-84 days post-vaccination as the control window.

RESULTS

Over 13 million beneficiaries were vaccinated in each season. USPRT found a low magnitude signal for GBS in both seasons. SCRI analyses did not find excess GBS risk following any influenza vaccine for days 1-42 post-vaccination in either season. In the 2015-2016 season, for the 8-21 day window, our chart-confirmation showed an attributable GBS risk of 0.87 (95% CI: 0.16, 1.49) and 1.68 (95% CI: 0.69, 2.41) cases per million vaccinees after all seasonal and high dose (HD) vaccines, respectively, an elevated GBS risk for beneficiaries aged ≥75 years following all seasonal vaccines (OR: 2.25; 95% CI: 1.15, 4.39) and HD vaccine (OR: 3.67, 95% CI: 1.52, 8.85), and an elevated GBS risk for males who received seasonal vaccines (OR: 2.18; 95% CI: 1.15, 4.15) and HD vaccine (OR: 3.33; 95% CI: 1.35, 8.20). The finding of elevated GBS risk with advancing age and in males is consistent with literature; however, a distinction between HD and SD was a new finding. In the 2016-17 season, for the 8-21 day window, attributed cases showed an attributable GBS risk of 0.87 (95% CI: 0.03, 1.61) and 1.11 (95% CI: 0.00, 2.01) cases per million vaccinees after all seasonal and HD vaccines, respectively. We found no excess GBS risk for standard dose vaccines in the 8-21 day window in either season.

CONCLUSIONS

Our primary analysis finding of no excess GBS risk during both seasons was reassuring. The slightly elevated GBS risk, although in the expected range, in the 8-21 day window after all seasonal and high dose vaccines, but not after standard dose vaccines is hypothesis-generating because the difference may be due to vaccine factors such as antigen amount or strains in various seasons or due to host factors.

Identifying the culprits in neurological autoimmune diseases

The target organ of neurological autoimmune diseases (NADs) is the central or peripheral nervous system. Multiple sclerosis (MS) is the most common NAD, whereas Guillain-Barré syndrome (GBS), myasthenia gravis (MG), and neuromyelitis optica (NMO) are less common NADs, but the incidence of these diseases has increased exponentially in the last few years. The identification of a specific culprit in NADs is challenging since a myriad of triggering factors interplay with each other to cause an autoimmune response. Among the factors that have been associated with NADs are genetic susceptibility, epigenetic mechanisms, and environmental factors such as infection, microbiota, vitamins, etc. This review focuses on the most studied culprits as well as the mechanisms used by these to trigger NADs.

•

Neurological autoimmune diseases are caused by a complex interaction between genes, environmental factors, and epigenetic deregulation.

•

Infectious agents can cause an autoimmune reaction to myelin epitopes through molecular mimicry and/or bystander activation.

•

Gut microbiota dysbiosis contributes to neurological autoimmune diseases.

•

Smoking increases the risk of NADs through inflammatory signaling pathways, oxidative stress, and Th17 differentiation.

•

Deficiency in vitamin D favors NAD development through direct damage to the central and peripheral nervous system.

Changing trends in IVIG use in pediatric patients: A retrospective review of practices in a network of major USA pediatric hospitals

The use of immunoglobulins is gradually increasing. Intravenous immunoglobulins (IVIG) are used as replacement therapy for primary and secondary immune deficiencies, and as an anti-inflammatory and immunomodulatory medication for the treatment of neurologic, dermatologic, and rheumatologic diseases. The objective of this study was to analyze trends in the IVIG use in pediatric patients hospitalized to 47 US-based children's hospitals from 2007 to 2014. IVIG was used for the treatment of >2300 primary diagnoses in 53,648 unique patients. The number of IVIG admissions increased by 30.2% during the study period, while the mean rate of IVIG admissions/100,000 admissions increased only 5.8%. Most patients receiving IVIG were children and adolescents. IVIG was frequently used off-label or for the treatment of FDA-approved indications in children under two years of age and BMT patients <20 years of age. Primary immune deficiencies represented only 1.2% of all IVIG admissions. Pediatric patients with mucocutaneous lymph node syndrome (Kawasaki disease, KD) and idiopathic thrombocytopenic purpura (ITP) were two primary consumers of the IVIG. Another top-ranked indications were acute infectious polyneuritis (Guillain-Barré syndrome, GBS) and prophylaxis of infections in patients receiving antineoplastic chemotherapy. IVIG usage is a dynamic process guided by emerging evidence and FDA approval for new indications. IVIG was mostly prescribed for treatment of diseases with pathologic immune responses to foreign of self-antigens. These indications usually, require higher amounts of IVIG per admission. More studies are needed to understand whether IVIG treatments of off-label indications are effective and cost-efficient.

Guillain-Barre syndrome outbreak in Peru: Association with polymorphisms in IL-17, ICAM1, and CD1

Background

Guillain–Barre Syndrome (GBS) is considered a complex disorder with significant environmental effect and genetic susceptibility. Genetic polymorphisms in CD1E, CD1A, IL‐17, and/or ICAM1 had been proposed as susceptibility genetic variants for GBS mainly in Caucasian population. This study explores the association between selected polymorphisms in these genes and GBS susceptibility in confirmed GBS cases reported in mestizo population from northern Peru during the most recent GBS outbreak of May 2018.

Methods

A total of nine nonrelated cases and 11 controls were sequenced for the polymorphic regions of CD1A, CD1E, IL‐17, and ICAM1.

Results

We found a significant protective association between heterozygous GA genotype in ICAM1 (241Gly/Arg) and GBS (p < .047). IL‐17 was monomorphic in both controls and patients. No significant differences were found in the frequency of SNPs in CD1A and CD1E between the group with GBS patients and healthy controls.

Conclusion

ICAM1 polymorphisms might be considered as potential genetic markers of GBS susceptibility. Further studies with larger sample size will be required to validate these findings.

Isolated adrenocorticotropic hormone (ACTH) deficiency and Guillain-Barré syndrome occurring in a patient treated with nivolumab

The increased use of immune checkpoint inhibitors (ICIs) has led to the observation of a variety of immune-related adverse events (irAEs). These irAEs occur usually within the first months after ICIs onset and can involve theorically all organs. We describe two rare irAEs occurring in a 70-year-old caucasian man who was treated with nivolumab for an advanced urothelial cancer of the left kidney. He developed an isolated adrenocorticotropic hormone deficiency that was diagnosed at week 19 and a neurological complication that appeared at week 79 and initially confounded with a lumbar spinal stenosis. Diagnosis of Guillain-Barré syndrome was finally confirmed with the complete resolution of symptoms after 5 days of intravenous immunoglobulin and corticosteroids. We highlight the importance of quickly recognising these potential life-threatening irAEs such as cortisol insufficiency and neurologic adverse events whose initially presentation could be non-specific.

A Rare Case of Acute Transverse Myelitis (ATM) and Acute Motor and Sensory Axonal Neuropathy (AMSAN) Overlap

Concomitant acute transverse myelitis (ATM) and Guillain-Barre syndrome (GBS) is described as GBS and ATM overlap. Its presentation varies greatly, thus making the diagnosis difficult. Overlap syndrome is more commonly associated with acute motor axonal neuropathy (AMAN) subtype of GBS. However, we present a case of a middle-aged gentleman with combined ATM and acute motor and sensory axonal neuropathy (AMSAN) subtype of GBS. This combination is quite rare, and only a few cases have been reported so far.

Long-term outcomes of Guillain-Barré syndrome possibly associated with Zika virus infection

Background

This prospective cohort investigation analyzed the long-term functional and neurologic outcomes of patients with Zika virus-associated Guillain-Barré syndrome (GBS) in Barranquilla, Colombia.

Methods

Thirty-four Zika virus-associated GBS cases were assessed a median of 17 months following acute GBS illness. We assessed demographics, results of Overall Disability Sum Scores (ODSS), Hughes Disability Score (HDS), Zung Depression Scale (ZDS), and Health Related Quality of Life (HRQL) questionnaires; and compared outcomes indices with a normative sample of neighborhood-selected control subjects in Barranquilla without GBS.

Results

Median age at time of acute neurologic onset was 49 years (range, 10–80); 17 (50%) were male. No deaths occurred. At long-term follow-up, 25 (73%) patients had a HDS 0–1, indicating complete / near complete recovery. Among the group, HDS (mean 1.4, range 0–4), ODSS (mean 1.9, range 0–9) and ZDS score (mean 34.4, range 20–56) indicated mild / moderate ongoing disability. Adjusting for age and sex, Zika virus-associated GBS cases were similar to a population comparison group (n = 368) in Barranquilla without GBS in terms of prevalence of physical or mental health complaints, though GBS patients were more likely to have an ODSS of ≥ 1 (OR 8.8, 95% CI 3.2–24.5) and to suffer from moderate / moderate-severe depression (OR 3.89, 95% CI 1.23–11.17) than the comparison group.

Conclusions

Long-term outcomes of Zika virus-associated GBS are consistent with those associated with other antecedent antigenic stimuli in terms of mortality and ongoing long-term morbidity, as published in the literature. Persons with Zika virus-associated GBS more frequently reported disability and depression after approximately one year compared with those without GBS.

Gulllain-Barre Syndrome After Trivalent Influenza Vaccination in Adults

Lines of evidence suggest trivalent influenza vaccination may be associated with Guillain-Barre syndrome (GBS), an immune-mediated acute inflammatory neuropathy. On the other hand, this vaccination protects against influenza infection, which has been demonstrated as a trigger of GBS. To clarify the net effect of trivalent influenza vaccines on GBS, we conducted a retrospective nationwide nested case-control study using the database of the Taiwan National Health Insurance program. We identified 182 hospitalized patients with GBS aged ≥50 years from 2007 to 2015 as the cases, and 910 hospitalized patients, matched by gender, age, date of hospitalization, comorbidities, and medications, as the control subjects. Nearby and remote exposures of vaccination were defined as subjects who had received trivalent influenza vaccine 42 (nearby exposure) and 90 days (remote exposure) before the date of hospitalization, respectively. We found 7 (3.85%) GBS patients and 26 (2.86%) matched control subjects who demonstrated nearby exposures of influenza vaccine (odds ratio: 1.46, 95% confidence interval: 0.56-3.78). Seventeen (9.34%) GBS patients were exposed to influenza vaccines remotely, while the number of remote exposure of influenza vaccines in matched control subjects was 72 (7.91%, odds ratio: 1.26, 95% confidence interval: 0.67-2.38). These results do not support an association between trivalent influenza vaccine and GBS among the patients aged ≥50 years.

Regional variation of Guillain-Barré syndrome

Guillain-Barré syndrome is a heterogeneous disorder regarding the clinical presentation, electrophysiological subtype and outcome. Previous single country reports indicate that Guillain-Barré syndrome may differ among regions, but no systematic comparative studies have been conducted. Comparative studies are required to identify factors determining disease susceptibility, variation and prognosis, and to improve diagnostic criteria. The International Guillain-Barré Syndrome Outcome Study is a prospective, observational cohort study including all patients within the diagnostic spectrum, aiming to describe the heterogeneity of Guillain-Barré syndrome worldwide. The current study was based on the first 1000 inclusions with a follow-up of at least 1 year and confirmed the variation in clinical presentation, course and outcome between patients. The full clinical spectrum of Guillain-Barré syndrome was observed in patients from all countries participating in the International Guillain-Barré Syndrome Outcome Study, but the frequency of variants differed between regions. We compared three regions based on geography, income and previous reports of Guillain-Barré syndrome subtypes: 'Europe/Americas', 'Asia' (without Bangladesh), and 'Bangladesh'. We excluded 75 (8%) patients because of alternative diagnoses, protocol violations, or missing data. The predominant clinical variant was sensorimotor in Europe/Americas (n = 387/562, 69%) and Asia (n = 27/63, 43%), and pure motor in Bangladesh (n = 74/107, 69%). Miller Fisher syndrome and Miller Fisher-Guillain-Barré overlap syndrome were more common in Asia (n = 14/63, 22%) than in the other two regions (Europe/Americas: n = 64/562, 11%; Bangladesh: n = 1/107, 1%) (P < 0.001). The predominant electrophysiological subtype was demyelinating in all regions (Europe/Americas: n = 312/573, 55%; Asia: n = 29/65, 45%; Bangladesh: n = 38/94, 40%). The axonal subtype occurred more often in Bangladesh (n = 34/94, 36%) than in Europe/Americas (n = 33/573, 6%) and other Asian countries (n = 4/65, 6%) (P < 0.001). In all regions, patients with the axonal subtype were younger, had fewer sensory deficits, and showed a trend towards poorer recovery compared to patients with the demyelinating subtype. The proportion of patients able to walk unaided after 1 year varied between Asia (n = 31/34, 91%), Europe/Americas (n = 334/404, 83%) and Bangladesh (n = 67/97, 69%) (P = 0.003). A similar variation was seen for mortality, being higher in Bangladesh (n = 19/114, 17%) than in Europe/Americas (n = 23/486, 5%) and Asia (n = 1/45, 2%) (P < 0.001). This study showed that factors related to geography have a major influence on clinical phenotype, disease severity, electrophysiological subtype, and outcome of Guillain-Barré syndrome.

A unicenter, prospective study of Guillain-Barré syndrome in Spain

OBJECTIVE

We report a prospective study analysing clinical characteristics, subtyping and prognosis in Guillain-Barré syndrome (GBS).

METHOD

The study was based on consecutive GBS patients admitted between 2009 and 2017. Disability was serially assessed using the GBS disability scale.

RESULTS

Fifty-six GBS patients were identified with an average age of 55 years (range, 5-86 years) and a male/female ratio of 2.1. The interval to nadir was <7 days in 59% of cases, and 7 to 28 days in the remainder; at nadir, 35.5% of patients were able to walk unaided, and 64.5% did not. Mechanical ventilation was needed in 20% of cases. There were two fatal cases. Clinical variants included paraparetic GBS seven cases, Miller Fisher syndrome one case, and acute sensory ataxic neuropathy (ASAN) one case. Serial electrophysiology showed a demyelinating pattern in 62.5% of cases, axonal in 28.5%, inexcitable in 1.8%, equivocal in 1.8%, and normal in 5.4%. Very early (1 to 4 days after onset) electrophysiology was done in 18 patients; equivocal or normal features in six of them evolved into an axonal pattern in four. Reversible conduction failure of sensitive nerves occurred in ASAN. Antiganglioside antibodies were only detected in axonal GBS. At 24-month follow-up, functional outcome did not differ between demyelinating and axonal GBS. Clinico-pathological correlation in an early fatal case is reported.

CONCLUSIONS

This GBS study demonstrates comparable clinical features to previous investigations from well-defined populations. There was a relatively high prevalence of axonal GBS. We provide new pathophysiological insights on nerve conduction alterations.

Postoperative Guillain-Barré Syndrome, a Neurologic Complication that Must Not Be Overlooked: A Literature Review

BACKGROUND

Guillain-Barré syndrome (GBS) is an uncommon, yet life-threatening postoperative neuropathic complication that is easily neglected, and hence, timely treatment is not provided in the clinics. This review aims to summarize the clinical features of postoperative GBS, and thus, improve the understanding of postoperative GBS.

METHODS

We reviewed the literature on postoperative GBS and assessed the demographic information, clinical manifestation, operation, time of onset of postoperative GBS, and prognosis.

RESULTS

A total of 33 cases of postoperative GBS were included in this study. The average age of patients with postoperative GBS was 46.9 years, and there was a peak in occurrence of GBS between ages 50 and 70 years. Men seemed more likely to have postoperative GBS than did women, with a ratio of 2.67:1. Progressive muscular weakness, present in 31 of the cases, was the most common presentation. Patients with spinal surgery were at further increased risk for GBS, and 84.8% of the patients with GBS had a good prognosis after prompt treatment.

CONCLUSIONS

Surgery is probably a potential risk factor for the occurrence of GBS. Early diagnosis and prompt treatment are imperative to reduce mortality.

Inflammatory demyelinating polyneuropathy after total hip arthroplasty

Inflammatory demyelinating polyneuropathy is a rare but devastating condition. Guillain-Barré syndrome is the most common cause with acute inflammatory demyelinating polyneuropathy being the most common subtype that follows a monophasic course and does not recur. Chronic inflammatory demyelinating polyneuropathy occurs when symptoms persist for greater than 8 weeks. With many proposed etiologies, few reports have described acute inflammatory demyelinating polyneuropathy after total joint arthroplasty. To our knowledge, this is the first case report of chronic inflammatory demyelinating polyneuropathy developing after total hip arthroplasty that was further complicated by dislocation.

Neurological Implications of Zika Virus Infection in Adults

The 2015-2016 epidemic of Zika virus (ZIKV) in the Americas and the Caribbean was associated with an unprecedented burden of neurological disease among adults. Clinically, Guillain-Barre syndrome (GBS) predominated among regions affected by the ZIKV epidemic, but the spectrum of neurological disease in the adults appears broader as cases of encephalopathy, encephalitis, meningitis, myelitis, and seizures have also been reported. A para-infectious temporal profile of ZIKV-associated GBS (ZIKV-GBS) has been described in clinical studies, which may suggest a direct viral neuropathic effect. However, ZIKV neuropathogenesis has not yet been fully understood. Mechanisms for ZIKV-GBS and other neurological syndromes have been hypothesized, such as adaptive viral genetic changes, immunological interactions with other circulating flaviviruses, and host and factors. This review summarizes the current evidence on ZIKV-associated neurological complications in the adults.

Natural Diterpenoid Oridonin Ameliorates Experimental Autoimmune Neuritis by Promoting Anti-inflammatory Macrophages Through Blocking Notch Pathway

The diterpenoid compound, Oridonin, extracted from the Chinese herb, Rabdosia rubescens, possesses multiple biological activities and properties. Oridonin exhibited efficient anti-inflammatory activity by inducing a switch in macrophage polarization to the anti-inflammatory phenotype through inhibition of the Notch pathway in our in vitro study; therefore, its potential therapeutic effects were further investigated in the animal model of human Guillain-Barré syndrome (GBS) and other polyneuropathies - experimental autoimmune neuritis (EAN). Either preventive or therapeutic treatments with Oridonin greatly attenuated disease peak severity, suppressed paraparesis, shortened disease duration, and even delayed EAN onset. Progression of neuropathic pain, demyelination, inflammatory cellular accumulations, and inflammatory cytokines in peripheral nerves were significantly attenuated. Meanwhile, accumulation of immune cells in the spinal roots and microglial activation in the lumbar spinal cord were also reduced. Interestingly, Oridonin treatment significantly increased the proportion of anti-inflammatory macrophages and made them locally dominant among all infiltrated macrophages in the peripheral nerves. The down-regulation of local Notch pathway proteins, together with our in vitro results indicated their possible involvement. Taken together, our results demonstrated that Oridonin effectively suppressed EAN by attenuating local inflammatory reaction and increasing the proportion of immune regulating macrophages in the peripheral nerves, possibly through blockage of the Notch pathway, which suggests Oridonin as a potential therapeutic candidate for human GBS and neuropathies.

How Different is AMAN from AIDP in Childhood GBS? A Prospective Study from North India

OBJECTIVES

To compare the clinical profile and short-term outcome of children with axonal and demyelinating subtypes of childhood Guillain Barré syndrome (GBS).

METHODS

This is a prospective observational study conducted in a tertiary care teaching hospital in North India. Consecutive children with Guillain Barré syndrome were recruited to compare the clinical profile and short term outcome among the subtypes.

RESULTS

Among 9847 children admitted to the emergency, 95 had acute flaccid paralysis; 57 of whom had GBS. Electrophysiological studies were completed in 57; of whom 20 had acute inflammatory demyelinating polyneuropathy (AIDP); 19 had acute motor axonal neuropathy (AMAN); 12 had non-reactive nerves; five were unclassifiable; 1 had acute motor sensory axonal neuropathy (AMSAN). More children in AMAN group had preceding gastroenteritis (4 vs. 2), while AIDP group had upper respiratory infections (12 vs. 7). Ataxia was only seen in AIDP subtype while wrist drop, foot drop and hyperreflexia were seen only with AMAN subtype. Respiratory muscle involvement (6 vs. 3) and artificial ventilation (5 vs. 2) was more in AMAN. At discharge, children with AIDP were less likely to be non-ambulant (12 vs. 6, p = 0.036). Mean disability scores at hospital discharge (4.9 ± 1.2 vs. 4 ± 0.9, p = 0.015) and at last follow-up (0.7 ± 1.01 vs. 0.05 ± 0.2, p = 0.016) were higher in AMAN. Children with AIDP were more likely to achieve normalcy on follow-up (19 vs. 12, p = 0.023).

CONCLUSIONS

Children with AMAN appear to have a more severe clinical course; higher short-term morbidity; and slower recovery than those with AIDP.

Edible Coatings Fortified With Carvacrol Reduce Campylobacter jejuni on Chicken Wingettes and Modulate Expression of Select Virulence Genes

Campylobacter jejuni, a leading cause of foodborne disease in humans, associate primarily with consumption of contaminated poultry and poultry products. Intervention strategies aimed at reducing C. jejuni contamination on poultry products could significantly reduce C. jejuni infection in humans. This study evaluated the efficacy of gum arabic (GA) and chitosan (CH) fortified with carvacrol (CR) as an antimicrobial coating treatment for reducing C. jejuni on chicken wingettes. Aforementioned compounds are generally recognized as safe status compounds obtained from gum arabic tree, crustaceans and oregano oil respectively. A total of four separate trials were conducted in which wingettes were randomly assigned to baseline, saline control (wingettes washed with saline), GA (10%), CH (2%), CR (0.25, 0.5, or 1%) or their combinations. Each wingette was inoculated with a cocktail of four wild-type strains of C. jejuni (∼7.5 log10 cfu/sample). Following 1 min of coating in aforementioned treatments, wingettes were air dried (1 h) and sampled at 0, 1, 3, 5, and 7 days of refrigerated storage for C. jejuni and total aerobic counts (n = 5 wingettes/treatment/day). In addition, the effect of treatments on wingette color was measured using a Minolta colorimeter. Furthermore, the effect of treatments on the expression of C. jejuni survival/virulence genes was evaluated using real-time quantitative PCR. Results showed that all three doses of CR, CH or GA-based coating fortified with CR reduced C. jejuni from day 0 through 7 by up to 3.0 log10 cfu/sample (P < 0.05). The antimicrobial efficacy of GA was improved by CR and the coatings reduced C. jejuni by ∼1 to 2 log10 cfu/sample at day 7. Moreover, CH + CR coatings reduced total aerobic counts when compared with non-coated samples for a majority of the storage times. No significant difference in the color of chicken wingettes was observed between treatments. Exposure of pathogen to sublethal concentrations of CR, CH or combination significantly modulated select genes encoding for energy taxis (cetB), motility (motA), binding (cadF), and attachment (jlpA). The results suggest that GA or CH-based coating with CR could potentially be used as a natural antimicrobial to control C. jejuni in postharvest poultry products.

Clinical Characteristics of Intravenous Injection of Monosialotetrahexosyl Ganglioside Sodium-Related Guillain-Barre Syndrome

Introduction: Guillain Barre Syndrome (GBS) is an acute inflammatory immune-mediated multiple nerve root neuropathy. GBS primarily damages the spinal nerve root and peripheral nerves, but can also affect the cranial nerves and cause acute demyelination. This study analyzed the clinical features of intravenous injection of monosialotetrahexosyl ganglioside sodium-related Guillain-Barre syndrome (GRD-GBS). Methods: We retrospectively studied 12 patients who developed GRD-GBS after receiving monosialotetrahexosyl ganglioside sodium treatment in association with recent trauma, surgery, acute cerebrovascular disease, or chronic peripheral neuropathy. Clinical characteristics, electrophysiological examinations, serum-specific antibodies, and prognosis were assessed. As controls, we selected 12 patients hospitalized with non-ganglioside-related (NGRD)-GBS. Results: The positive rate of the ganglioside antibody test was significantly higher in the GRD-GBS group (66.67%) than in the NGRD-GBS group (8.33%). CSF protein levels were similar between the groups, but the incidence of blood-nerve-barrier (BNB) disruption was higher in the GRD-GBS group. Patient scores for the Hughes Functional Grading Scale (HFGS), a disability scale, were higher (more severe disability) in the GRD-GBS group than in the NGRD-GBS group. The HFGS scores of the GRD-GBS group did not change between peak onset and 30 days after discharge, but did change significantly by 90 days after discharge, while scores were significantly lower at both 30 and 90 days after discharge in the NGRD-GBS group. Conclusions: GRD-GBS patients showed more severe clinical manifestations, poorer prognosis, and slower recovery than patients with NGRD-GBS. Ganglioside treatment should be used with extreme caution in patients with trauma that damages the BNB.

The serum SA levels are significantly increased in sepsis but decreased in cirrhosis

Most of proteins in human blood circulation are glycoproteins with one or more covalently linked N- or O-linked glycans. Sialic acid (SA) generally occurs as the terminal monosaccharide on the glycans. SA in glycoproteins modulates a wide range of physiological and pathological processes and has been routinely measured in hospital since 1950s. Increased serum SA levels have been associated with different types of cancers. However, a systematic comparison of the serum SA levels in different types of human diseases has not been reported. In current study, 160,537 clinical lab test results of serum SA levels from healthy individuals and patients with 64 different types of diseases during the past 5 years in our hospital were retrieved and analyzed. Based on the mean (SD), median, and p (-Log₁₀p) values, we found that patients suffering 55 different types of cancer and noncancer diseases such as sepsis, pancreatitis, bone cancer, rheumatoid arthritis, pancreatic cancer, and encephalitis had significantly (p<0.05, -Log₁₀p>1.30) increased median serum SA levels whereas patients suffering hepatic encephalopathy, cirrhosis, renal cyst, and hepatitis had significantly decreased median serum SA levels compared to that of healthy controls. Moreover, the greatest increase in the mean (SD) and -Log₁₀p values was observed in sepsis and pancreatitis, respectively, but not in cancers. Thus, the regulations of serum SA levels were much more complicated than previously assumed. Understanding the molecular mechanisms behind these observations would make serum SA a useful biomarker to facilitate personalized diagnosis and treatment for patients with different diseases.

Efficient design and analysis of randomized controlled trials in rare neurological diseases: An example in Guillain-Barré syndrome

BACKGROUND

Randomized controlled trials (RCTs) pose specific challenges in rare and heterogeneous neurological diseases due to the small numbers of patients and heterogeneity in disease course. Two analytical approaches have been proposed to optimally handle these issues in RCTs: covariate adjustment and ordinal analysis. We investigated the potential gain in efficiency of these approaches in rare and heterogeneous neurological diseases, using Guillain-Barré syndrome (GBS) as an example.

METHODS

We analyzed two published GBS trials with primary outcome 'at least one grade improvement' on the GBS disability scale. We estimated the treatment effect using logistic regression models with and without adjustment for prognostic factors. The difference between the unadjusted and adjusted estimates was disentangled in imbalance (random differences in baseline covariates between treatment arms) and stratification (change of the estimate due to covariate adjustment). Second, we applied proportional odds regression, which exploits the ordinal nature of the GBS disability score. The standard error of the estimated treatment effect indicated the statistical efficiency.

RESULTS

Both trials were slightly imbalanced with respect to baseline characteristics, which was corrected in the adjusted analysis. Covariate adjustment increased the estimated treatment effect in the two trials by 8% and 18% respectively. Proportional odds analysis resulted in lower standard errors indicating more statistical power.

CONCLUSION

Covariate adjustment and proportional odds analysis most efficiently use the available data and ensure balance between the treatment arms to obtain reliable and valid treatment effect estimates. These approaches merit application in future trials in rare and heterogeneous neurological diseases like GBS.

Co-existent ulcerative colitis and Guillain-Barré syndrome: a case report and literature review

Ulcerative colitis (UC) is a chronic and recurrent inflammatory disease involving the intestine, and Guillain-Barré Syndrome (GBS) is rapid-onset muscle weakness caused by the immune system damaging the peripheral nervous system. UC and GBS can be caused by immune system abnormalities and can co-exist. To date, there are 7 reported cases of GBS in patients with UC. However, only one patient developed UC after GBS treatment. We report a rare case of UC that appeared after intravenous immunoglobulin therapy for GBS. This case report and literature review will allow accurate and prompt diagnosis of co-existent GBS and UC.

Comprehensive rehabilitation treatment for pregnant women with Guillain-Barré syndrome - a case report

Guillain-Barré syndrome (GBS) is an acute demyelinating poliradioculopathy and autoimmune condition, with a fast rapid natural course, and with high disability and usually episodic immune treatment. Clinical features include areflexia, limb weakness and uncommonly, sensory loss proceeding to neuromuscular paralysis involving bulbar, facial and respiratory function with maximum severity of symptoms atin 2-4 weeks. The eEtiology of GBS is not incompletely understood, however, prognosis is usually good with early detection and prompt treatment. In thise paper, we present a unique case of comprehensive rehabilitation treatment for a pregnant woman with GBS atin the 8th week of pregnancy. On the basis of this case report, we discuss possible and safe rehabilitation treatment for women in the first trimester of pregnancy, with significantly weakened muscle strength, after stabilizsation of vital signs and immunotherapy. The paper describes comprehensive care provided to the pregnant woman with teraplegia, hyperstesia and dysphagia after stabiliszation of vital signs, which was conducted until delivery atin the 39th week of pregnancy. This article is licensed under a Creative Commons Attribution-ShareAlike 4.0 International License. null

Integrative metabolomics reveals unique metabolic traits in Guillain-Barré Syndrome and its variants

Guillain-Barré syndrome (GBS) is an acute fatal progressive disease caused by autoimmune mechanism mainly affecting peripheral nervous system. Although the syndrome is clinically sub-classified into several variants, specific biomarker and exact pathomechanism of each subtypes are not well elucidated yet. In current study, integrative metabolomic and lipidomic profiles were acquisitioned from cerebrospinal fluid samples of 86 GBS from three variants and 20 disease controls. And the data were systematically compared to our previous result on inflammatory demyelination disorders of central nervous system (IDDs) and healthy controls. Primary metabolite profiles revealed unique metabolic traits in which 9 and 7 compounds were specifically changed in GBS and IDD, respectively. Next, the biomarker panel with 10 primary metabolites showed a fairly good discrimination power among 3 GBS subtypes, healthy controls, and disease controls (AUCs ranged 0.849-0.999). The robustness of the biomarker panel was vigorously validated by multi-step statistical evaluation. Subsequent lipidomics revealed GBS variant-specific alteration where the significant elevations of lyso-phosphatidylcholines and sphingomyelins were unique to AIDP (acute inflammatory demyelinating polyneuropathy) and AMAN (acute motor axonal neuropathy), respectively. And metabolome-wide multivariate correlation analysis identified potential clinical association between GBS disability scale (Hughes score) and CSF lipids (monoacylglycerols, and sphingomyelins). Finally, Bayesian network analysis of covarianced structures of primary metabolites and lipids proposed metabolic hub and potential biochemical linkage associated with the pathology.

Risk factors for respiratory failure in Guillain-Barré syndrome in Bangladesh: a prospective study

Objective

We investigated clinical, biological, and electrophysiological risk factors for mechanical ventilation (MV) and patient outcomes in Bangladesh using one of the largest, prospective Guillain-Barré syndrome (GBS) cohorts in developing world.

Methods

A total of 693 GBS patients were included in two GBS studies conducted between 2006 and 2016 in Dhaka, Bangladesh. Associations between baseline characteristics and MV were tested using Fisher's exact test, χ² test, or Mann-Whitney U-test, as appropriate. Risk factors for MV were assessed using multivariate logistic regression. Survival analysis was performed using Kaplan-Meier method; comparisons between groups performed using log-rank test.

Results

Of 693 patients, 155 (23%) required MV (median age, 26 years; interquartile range [IQR] 17-40). Among the ventilated patients, males were predominant (68%) than females. The most significant risk factor for MV was bulbar involvement (adjusted odds ratio [AOR]:19.07; 95% CI = 89.00-192.57, P = 0.012). Other independently associated factors included dysautonomia (AOR:4.88; 95% CI = 1.49-15.98, P = 0.009) and severe muscle weakness at study entry (AOR:6.12; 95% CI = 0.64-58.57, P = 0.048). At 6 months after disease onset, 20% of ventilated and 52% of non-ventilated patients (P < 0.001) had recovered completely or with minor symptoms. Mortality rate was significantly higher among ventilated patients than non-ventilated patients (41% vs. 7%, P < 0.001).

Interpretation

Bulbar involvement, dysautonomia and severe muscle weakness were identified as the most important risk factors for MV among GBS patients from Bangladesh. The findings may help to develop predictive models for MV in GBS in developing countries to identify impending respiratory failure and proper clinical management of GBS patients.

Intensive Care Management of the Neuromuscular Patient

Neuromuscular emergencies are a distinct group of acute neurological diseases with distinct characteristic presentations. Patients who suffer from this group of diseases are at immediate risk of losing protection of their native airway as well as aspirating orogastric contents. This is secondary to weakness of the muscles of the oropharynx and respiratory muscles. Although some neuromuscular emergencies such as myasthenia gravis or Guillain-Barré syndrome are well understood, others such as critical illness myopathy and neuropathy are less well characterized. In this chapter, we have discussed the pathophysiology, diagnostic evaluation, and management options in patients who are admitted to the intensive care unit. We have also emphasized the importance of a thorough understanding of the use of pharmacological anesthetic agents in this patient population.

Prevalence and outcomes of Guillain-Barré syndrome among pediatrics in Saudi Arabia: a 10-year retrospective study

BACKGROUND

Guillain-Barré syndrome (GBS) is a progressive acute form of paralysis most probably secondary to an immune-mediated process. GBS among Saudis has been seldom investigated, which leaves both clinicians and researchers with scarcity in knowledge. Therefore, this study aims to assess the prevalence and clinical prognosis of GBS among pediatrics admitted with acute paralysis at a large healthcare facility in Riyadh, Saudi Arabia.

METHODS

This retrospective study reviewed patients' medical records between 2005 and 2015. Eligible cases were children (<14 years old) admitted to the hospital complaining of acute paralysis and later diagnosed with one form or variant of GBS. Pearson's chi-square, Fisher's exact test, and binary logistic regression were employed to analyze the collected data.

RESULTS

The prevalence of GBS was 49%. The male-to-female ratio was 1.45:1. The mean ± standard deviation age was 7±3.7 years. There were 34 (69.4%) cases with progression to maximum paralysis in ≤2 weeks, while 15 (30.6%) cases occurred beyond 2 weeks. Males (n=24, 82.8%) were more likely to endure progression to maximum paralysis in ≤2 weeks after the disease onset, compared to females (n=10, 50%), P=0.014. All cases complaining of respiratory problems exhibited a progression to maximum paralysis in ≤2 weeks, compared to those with no respiratory problems, P=0.027. Residual paralysis at 60 days post disease onset was highly associated with GBS patients of age 8-14 years (n=15, 65.2%), compared to younger patients (n=8, 30.8%), P=0.016. Patients admitted in colder seasons (n=14, 63.6%) were more likely to suffer residual paralysis too, compared to those in warmer seasons (n=9, 33.3%), P=0.035. GBS cases who complained of facial weakness (n=9, 75%) and ocular abnormalities (n=10, 71.4%) were also more likely to endure residual paralysis at 60 days post disease onset, P=0.025 and P=0.03, respectively.

CONCLUSION

Male gender could be a determinant of rapid progression to maximum paralysis, while the older age group in pediatrics is expected to endure residual paralysis at 60 days post disease onset. GBS can be accounted as a rare disease, especially in pediatrics, so confirmed cases should be investigated comprehensively for research purposes.

Systematic review of factors associated with the development of Guillain-Barré syndrome 2007-2017: what has changed?

OBJECTIVE

The objective of this study was to describe the factors associated with the development of Guillain-Barré syndrome, both infectious and non-infectious, during and after the A(H1N1) influenza pandemic in 2009 and the recent Zika virus epidemic in the Americas.

METHOD

Systematic review of literature on factors associated with the development of the Guillain-Barré syndrome published between 2007 and 2017 listed in EBSCO, MEDLINE and LILACS databases. The quality of the studies was evaluated using the Newcastle Ottawa Scale.

RESULTS

Thirty-four articles met inclusion criteria and were selected for analysis. Their quality was considered good in relation to most of the items evaluated. Many aetiological agents had the results of association with Guillain-Barré syndrome, among them Campylobacter jejuni, influenza vaccine - both pandemic and seasonal vaccines, respiratory infection, gastrointestinal infection among others. The aetiological agents found are, in most part, the same reported prior to the study period. The association with surgeries, chikungunya virus (CHIKV), Zika virus and quadrivalent human papillomavirus vaccine stand out as new aetiological agents in the list of the various possible agents that trigger Guillain-Barré syndrome reported in the study period. There were no Brazilian studies identified during this period.

CONCLUSIONS

The results of the review reaffirmed C. jejuni as the major trigger of GBS, whereas the association of influenza vaccines and GBS is less clear; Zika virus infection in association with GBS was found in only one study.

A Cotransformation Method To Identify a Restriction-Modification Enzyme That Reduces Conjugation Efficiency in Campylobacter jejuni

Conjugation is an important mechanism for horizontal gene transfer in Campylobacter jejuni, the leading cause of human bacterial gastroenteritis in developed countries. However, to date, the factors that significantly influence conjugation efficiency in Campylobacter spp. are still largely unknown. Given that multiple recombinant loci could independently occur within one recipient cell during natural transformation, the genetic materials from a high-frequency conjugation (HFC) C. jejuni strain may be cotransformed with a selection marker into a low-frequency conjugation (LFC) recipient strain, creating new HFC transformants suitable for the identification of conjugation factors using a comparative genomics approach. To test this, an erythromycin resistance selection marker was created in an HFC C. jejuni strain; subsequently, the DNA of this strain was naturally transformed into NCTC 11168, an LFC C. jejuni strain, leading to the isolation of NCTC 11168-derived HFC transformants. Whole-genome sequencing analysis and subsequent site-directed mutagenesis identified Cj1051c, a putative restriction-modification enzyme (aka CjeI) that could drastically reduce the conjugation efficiency of NCTC 11168 (>5,000-fold). Chromosomal complementation of three diverse HFC C. jejuni strains with CjeI also led to a dramatic reduction in conjugation efficiency (∼1,000-fold). The purified recombinant CjeI could effectively digest the Escherichia coli-derived shuttle vector pRY107. The endonuclease activity of CjeI was abolished upon short heat shock treatment at 50°C, which is consistent with our previous observation that heat shock enhanced conjugation efficiency in C. jejuni Together, in this study, we successfully developed and utilized a unique cotransformation strategy to identify a restriction-modification enzyme that significantly influences conjugation efficiency in C. jejuni IMPORTANCE Conjugation is an important horizontal gene transfer mechanism contributing to the evolution of bacterial pathogenesis and antimicrobial resistance. Campylobacter jejuni, the leading foodborne bacterial organism, displays significant strain diversity due to horizontal gene transfer; however, the molecular components influencing conjugation efficiency in C. jejuni are still largely unknown. In this study, we developed a cotransformation strategy for comparative genomics analysis and successfully identified a restriction-modification enzyme that significantly influences conjugation efficiency in C. jejuni The new cotransformation strategy developed in this study is also expected to be broadly applied in other naturally competent bacteria for functional comparative genomics research.

Reversible conduction failure on the deep tendon reflex response recording in early Guillain-Barré syndrome

Objective

To describe the case of a patient with Guillain-Barré syndrome (GBS) showing early reversible conduction failure (RCF) detected by means of serial deep tendon reflex response (T-reflex) study.

Methods

A 36-year-old woman had a 5-day history of foot and hand paresthesias ascending to thighs and arms, throbbing interscapular and neck pain, mild to moderate tetraparesis, and areflexia. Nerve conduction studies (NCS) were performed on days 7 and 33 after onset.

Results

NCS showed an equivocal electrophysiologic pattern, just an isolated distal RCF being detected on the right radial nerve at initial examination. Motor latency on deltoid muscle after Erb's point stimulation was preserved. Sensory conduction velocities were normal or slightly slowed. Somatosensory evoked potentials from median and tibial nerves were normal. Initially, F-wave study demonstrated reversible abnormalities, consisting of multiple A waves and low F-wave persistence, minimal F-wave latencies being preserved. Biceps brachii T-reflex was normal, whereas Achilles T-reflex was absent bilaterally, appearing on the second study with normal T-wave morphology and latency, thus conforming to the requirements for RCF diagnosis. Soleus H-reflex was also initially absent.

Conclusions

Serial T-reflex study is a useful technique for detecting early RCF of proximal nerve trunks in early GBS.

Significance

T-reflex is useful tool for GBS in association with NCS.

Zika Virus-Associated Guillain-Barré Syndrome in a Returning US Traveler

Zika virus (ZIKV) infection has been associated with Guillain-Barré Syndrome (GBS). Roughly 60% of people in countries such as the U.S. live in areas at risk for seasonal spread of ZIKV. ZIKV belongs to a class of diseases that is not typically seen in hospital settings across the U.S. and Europe. We describe the case presentation, management, and treatment of ZIKV infection complicated by GBS. A 64-year-old woman with recent travel to the Dominican Republic presented with rash followed by an acute, ascending polyneuropathy consistent with GBS. She was confirmed to have an acute ZIKV infection by detection of ZIKV nucleic acid by reverse transcription-polymerase chain reaction. She met Brighton Collaboration criteria level 1 evidence for GBS. She received two courses of intravenous immunoglobulin and slowly improved, though still had weakness at discharge. More research is needed to identify the pathophysiology behind ZIKV-associated GBS and its optimal treatment. Prevention is fundamental to limiting infection and spread of ZIKV.

Guillain-Barré syndrome in children: subtypes and outcome

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Effects of sensory deficits on balance, functional status and trunk control in patients diagnosed with guillain-barre syndrome

Objectives:

To investigate the effects of sensory deficits on balance, functional status and trunk control in patients diagnosed with Guillain–Barré syndrome (GBS).

Methods:

Twenty patients who were diagnosed with GBS and who were in the neurology department of Mustafa Kemal University in 2017, participated in this descriptive study. There were 11 males and 9 females, and the average age was 41.55 ± 18.49 years. The trunk control of the GBS patients was assessed using the trunk impairment scale (TIS), reaching function was assessed using the functional reaching test (FRT) in the sitting position and body balance assessed using the Berg balance scale (BBS).Light touch was assessed using Semmes–Weinstein monofilament test, proprioception was assessed using the distal proprioception test and disability status was assessed using the Guillain–Barré syndrome disability scale (GBSDS).

Results:

We found a moderate, positive and significant correlation between proprioception scores and the BBS and between proprioception scores and the TIS. The correlation between proprioception and FRT in the sitting position and between proprioception and the GBSDS was not significant. We found a moderate and negative correlation between light touch and the FRT in the sitting position, TIS, BBS, but a moderate and positive correlation between light touch and the GBSDS.

Conclusion:

Neurologists and physiotherapists should both take sensory and motor function into consideration in the assessment and rehabilitation program of patients diagnosed with GBS.

An Unusual Presentation of Acute Weakness: Acute Inflammatory Demyelinating Polyneuropathy in a Patient with Psychiatric Illness

We report an unusual presentation of Guillain-Barré wherein a patient with an extensive history of psychiatric illness had a dream that his legs were crushed in an earthquake and awoke from the dream with paresthesias and rapid paralysis of bilateral lower extremities. This article discusses an atypical presentation of pathology and diagnostic evaluation for a form of Guillain-Barré called Acute Inflammatory Demyelinating Polyneuropathy (AIDP).

Guillain-Barré Syndrome and Low Back Pain: Two Cases and Literature Review

PURPOSE

To describe the clinical, electrophysiological, and lumbar magnetic resonance imaging (MRI) features of two cases of atypical Guillain-Barré syndrome (GBS). Methods We reported two GBS variant cases with initial and prominent symptoms of low back pain. We analysed their clinical, electrophysiological, and lumbar MRI features. Results Two patients with GBS reported low back pain as the initial and prominent symptom, which was not accompanied by limb weakness. The electrophysiological study showed abnormal F-waves in the common peroneal and tibial nerves, and acute polyradiculoneuropathy in the cauda equina. Examination of the cerebrospinal fluid (CSF) showed albuminocytologic dissociation. Serum was positive for GQ1b-IgM antibodies. Lumbar MRI showed gadolinium enhancement of the nerve roots and cauda equina. A standard regime of intravenous immunoglobulin markedly alleviated the low back pain. Conclusions Low back pain caused by GBS should be differentiated from other diseases. This initial or early prominent symptom may delay the diagnosis of GBS; therefore, it is important to conduct a detailed electrophysiological, CSF, and gadolinium-enhanced lumbar MRI analysis.

Commentary: Campylobacter and Hemolytic Uremic Syndrome

There are reports in the literature stating that Campylobacter infections can cause hemolytic uremic syndrome (HUS); however, a mechanism for how Campylobacter induces HUS has not been proposed by investigators. The most common bacterial inducer of HUS is the Shiga toxin-producing Escherichia coli (STEC), and a few cases of HUS are induced by an invasive Shigella dysenteriae or Streptococcus pneumoniae infection. Campylobacter spp. have not been shown to produce Shiga toxin (Stx) nor do they possess genetic elements capable of producing a Stx-like toxin. The neuraminidase associated with pneumococcal HUS has not been observed in Campylobacter. Therefore, in the absence of a well-defined toxic mechanism, it not clear that Campylobacter actually causes HUS.

Immune-mediated neuropathies

Since the discovery of an acute monophasic paralysis, later coined Guillain-Barré syndrome, almost 100 years ago, and the discovery of chronic, steroid-responsive polyneuropathy 50 years ago, the spectrum of immune-mediated polyneuropathies has broadened, with various subtypes continuing to be identified, including chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) and multifocal motor neuropathy (MMN). In general, these disorders are speculated to be caused by autoimmunity to proteins located at the node of Ranvier or components of myelin of peripheral nerves, although disease-associated autoantibodies have not been identified for all disorders. Owing to the numerous subtypes of the immune-mediated neuropathies, making the right diagnosis in daily clinical practice is complicated. Moreover, treating these disorders, particularly their chronic variants, such as CIDP and MMN, poses a challenge. In general, management of these disorders includes immunotherapies, such as corticosteroids, intravenous immunoglobulin or plasma exchange. Improvements in clinical criteria and the emergence of more disease-specific immunotherapies should broaden the therapeutic options for these disabling diseases.

Second IVIg course in Guillain-Barré syndrome patients with poor prognosis (SID-GBS trial): Protocol for a double-blind randomized, placebo-controlled clinical trial

One course of intravenous immunoglobulins (IVIg) of 2 g/kg is standard treatment in Guillain-Barré syndrome (GBS) patients unable to walk independently. Despite treatment some patients recover poorly, in part related to rapid consumption of IVIg, indicating that they may benefit from a second course of IVIg. The aim of the study is to determine whether a second course of IVIg, administered 1 week after start of the first course in patients with GBS and predicted poor outcome improves functional outcome on the GBS disability scale after 4 weeks. Secondary outcome measures include adverse events (AEs), Medical Research Council sumscore and GBS disability score after 8, 12, and 26 weeks, length of hospital and ICU admission, mortality, and changes in serum IgG levels. GBS patients of 12 years and older with a poor prognosis, based on the modified Erasmus GBS outcome score (mEGOS) at 1 week after start of the first IVIg course are eligible for randomization in this double-blind, placebo-controlled (IVIg or albumin) clinical trial. This study will determine if a second course of IVIg administered in the acute phase of the disease is safe, feasible, and effective in patients with GBS and a poor prognosis. This Dutch trial is registered prospectively as NTR 2224 in the Netherlands National Trial Register (NTR) which is the Primary Registry in the WHO Registry Network for the Netherlands.