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

Plasma Exchange in Five Patients with Acute Guillain Barré syndrome

During the last 3 years plasma exchanges were undertaken in 5 patients with acute Guillain Barré syndrome (G.B.S.). All the patients were admitted in the intensive respiratory care unit and had received six plasma exchange procedures over two weeks (each procedure consists of 2–3 L exchange). The first patient improved dramatically after the second exchange. Moderate success was obtained in two patients. One patient did not show any effect. The fifth patient received plasma exchange one day after her recovery phase had begun but the course of recovery remained uneffected.

The effect of plasma exchange was analysed as the patients’ response to motor activity, and compaired with a historical control group consisting of 50 acute G.B.S. patients admitted in the intensive respiratory care area over the last 25 years. Plasma exchange does not seem to have excerted any significant effect although at any given time the plasma exchange group had higher motor activity than that of the control group. A controlled clinical trial especially in the early phase of the disease is emphasized.

Membranous glomerulonephritis and Landry-Guillain-Barre syndrome

Two cases of idiopathic membranous glomerulonephritis associated with acute inflammatory demyelinating polyradiculoneuropathy (Landry-Guillian-Barre syndrome) are described. In both of the patients, the onset of the nephrotic syndrome coincided with the development of severe ascending sensorimotor neuropathy. Although this association has previously been reported in four other isolated cases, it is not generally recognized by nephrologists and may be of significance in the future understanding of the immunopathogenesis of both diseases.

Plasma exchange in chronic inflammatory demyelinating polyradiculoneuropathy

Eleven consecutive patients with progressive chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) underwent plasma exchange. Eight patients were previously unresponsive to prednisone, two were started on prednisone with plasma exchange, and one did not receive corticosteroids. Electrodiagnostic studies revealed evidence of an acquired demyelinating polyradiculoneuropathy with varying degrees of axonal degeneration. Neurologic impairment was monitored using conventional functional status index. Five patients demonstrated substantial clinical improvement, beginning 2 days to 3 weeks after initiating plasma exchange. Two additional patients improved following a second course of plasma exchange, and four patients demonstrated minimal or no change. Comparison of responding and nonresponding patients showed no differences related to the presence or absence of antecedent illness, duration of disease, duration of maximum weakness, or severity of impairment prior to plasma exchange. Responders had significantly prolonged F-response and motor distal latencies compared to nonresponders. Results in this unselected, consecutive patient trial suggest a temporal relationship between plasma exchange and clinical improvement in some patients with progressive CIDP.

Treatment of acute post-infective polyneuropathy by means of plasma exchange

15 patients with acute post-infective polyneuropathy of the Guillain-Barré type have been treated by means of plasma exchange. The clinical course and outcome of these patients is compared to that in a retrospectively matched control series who were treated with supportive therapy only. All patients had severe rapidly evolving muscle weakness and approximately half the patients in each group required ventilatory assistance. Both the duration of muscle weakness and the hospitalisation time was significantly shorter in the patients treated by means of plasma exchange. These results suggest that plasma exchange is of significant benefit in the treatment of patients with the Guillain-Barré syndrome.

Guillain-Barré syndrome and pemphigus foliaceus associated with D-penicillamine therapy

The Guillain-Barré syndrome and pemphigus foliaceus occurred simultaneously in a patient on long-term treatment with D-penicillamine. It is proposed that both conditions may have developed as a result of a disturbance of immunoregulation caused by D-penicillamine.

Cholinesterase activities in the autonomic nervous system of rabbits with experimental allergic neuritis: a biochemical study

Utilizing a colorimetric method with acetylthiocholine iodide (AThCh) as substrate and eserine and ethopropazine as inhibitors, the activities of AThCh-splitting enzymes, acetylcholinesterase (AChE) and non-specific esterase (psi ChE) were determined in different structures of the autonomic nervous system (ANS) from the left and from the right sides of rabbits with experimental allergic neuritis (EAN) and controls. The total activity of AThCh-splitting enzymes showed a highly significant decrease in the ganglion nodosum and in the ganglia of the thoracal and abdominal paravertebral sympathetic chain in rabbits with clinical symptoms of ANS-involvement. Lesser but still significant changes were found in EAN-rabbits with motor symptoms but without ANS symptoms. No definite changes could be found in the superior cervical ganglia, the cervical sympathetic trunk or the interganglionic portions of the abdominal and thoracal paravertebral sympathetic chains. In samples with decreased total enzyme activities, both AChE and psi ChE appeared to decrease to approximately the same extent. This study demonstrates that the activities of AThCh-splitting enzymes are decreased in EAN in parts of ANS innervating the heart, abdominal and pelvic organs, and suggests that enzyme activities not derived from the myelin sheath may be involved in the pathogenesis of this demyelinating disease.

In vivo demyelinating activity of sera from patients with Guillain-Barré syndrome

The in vivo demyelinating capacity of sera from 27 patients with Guillain-Barré syndrome (GBS) and 47 other individuals was studied by intraneural injection into rat sciatic nerves. The morphological features of the nerves in cross section taken just proximal to the site of needle insertion was assessed 48 hours after injection and the extent of demyelination was quantitated. All 27 GBS serum samples were obtained in the first three weeks of clinical disease. Of these, 11 (41%) produced demyelination. Demyelinative activity of GBS sera correlated only with severity of clinical disease (p less than 0.01). The extent of demyelination after intraneural injection of human sera was less intense on average than that produced by sera from animals with experimental allergic neuritis. Three of 40 (7.5%) sera obtained from normal subjects and patients with other neurological diseases also caused in vivo demyelination, although the activity was weaker and occurred less often than with GBS serum.

Effects of plasmapheresis on the course of experimental allergic neuritis in rabbits

Experimental allergic neuritis was induced in 30 rabbits with extract of bovine peripheral nerve in complete Freund's adjuvant. Of the 22 animals that completed the study, nine animals were plasmapheresed within two weeks of inoculation and 13 animals served as controls. The plasmapheresed animals developed a less severe form of EAN than the controls. Differences were apparent in clinical weakness, weight loss, degree of dispersion of the muscle action potential and histological changes.

The treatment of chronic relapsing and chronic progressive idiopathic inflammatory polyneuropathy by plasma exchange

Observations are reported on the effects of plasma exchange on three patients with chronic relapsing idiopathic inflammatory polyneuropathy and three with the chronic progressive form of this disorder. Substantial temporary improvement occurred in two of the chronic relapsing cases in relation to repeated plasma exchanges, but only slight improvement in the remainder. A striking feature was the rapidity of the effect in the patients that improved. The significance of these observations in relation to pathogenesis and to clinical management of the disorder is discussed.

Demonstration of oligoclonal immunoglobulin G in Guillain-Barré syndrome and lymphocytic meningoradiculitis by isoelectric focusing

Isoelectric focusing (IEF) of serum and CSF revealed oligoclonal IgG in 13 out of 16 patients with the Guillain-Barré syndrome (GBS), in 10 of them in serum only and in 3 in serum and CSF. Seventeen out of 19 patients with lymphocytic meningoradiculitis (LMR) showed oligoclonal IgG, 12 of them in CSF only. These findings, together with additional results, mean that in GBS oligoclonal IgG is synthesized mainly outside the CNS and in LMR within the CNS. Follow-up studies revealed changes in the oligoclonal IgG during the course of GBS and LMR. After treatment by plasma exchange the disappearance of oligoclonal IgG bands was followed by an improvement of GBS symptoms. The oligoclonal IgG bands returned in correlation with worsening of the disease. We were not able to elucidate the antibody character of oligoclonal IgG in GBS or LMR. No antibodies against the myelin basic protein (fragment 89-169) were detectable in the sera and CSF in any of the patients tested.

Treatment of Guillain-Barré syndrome by plasma exchange

Plasma exchange has been used for therapy in eight patients with the Guillain-Barré syndrome. All patients were severely ill. They became tetraplegic and showed cranial nerve involvement. Five patients received assisted respiration, but the others were also at risk of ventilatory insufficiency. Recovery was abrupt in all cases after the first plasma exchanges. Improvement was more marked when plasmapheresis was done on three successive days with plasma exchanges of 2.0-3.01 each in the initial progressive stage of the disease. A considerable advantage of this therapy is the avoidance of continued artificial respiration and nutrition, which both carry the risk of further complications.

Guillain-Barré syndrome and Hodgkin's disease--ultrastructural study of a peripheral nerve

A 46-year-old male patient developed the Guillain-Barre syndrome and recovered completely within 3 months. He had been treated 5 years previously for Hodgkin's disease, and during the neurological syndrome, relapse of the malignant lymphoma was discovered. On neuro-muscular biopsy, lymphocytes were observed penetrating Schwann cells. These neuropathological aspects confirm the auto-immune character of the nervous involvement.

Isoelectric focusing of CSF proteins in known or probable infectious neurological diseases and the Guillain-Barré syndrome

The CSF and serum proteins of 120 patients with known or probable infectious neurological diseases or the Guillain-Barré syndrome were examined with thin-layer IEF. All but two of these patients exhibited one or combinations of different CSF-protein aberrations in the acidic and alkaline range. Aberrant non-Ig fractions (including transferrin, the tau-fraction and gamma-trace protein) were found in frequencies varying between 4 and 48%. CSF Ig components of restricted heterogeneity, i.e. oligoclonal bands and/or regional increases of gamma-globulins, were more frequent in patients with (meningo-)encephalitic or (meningo-)-myelitis/radiculitic disorders (respectively 69 and 48%) than in subjects with meningitis or Guillain-Barré syndrome (17%). The occurrence of such Ig abnormalities was higher in subacute or chronic than in acute disease and in subjects examined greater than 4 weeks after the onset rather than earlier. Ig-band spectra with marked anodal extension were found predominantly in (meningo-)encephalitic disorders with infratentorial symptoms. Age and sex were not found to influence the occurrence of abnormal Ig fractions. Such components could be detected in spite of pronounced blood-CSF barrier defects.

Guillain-Barré syndrome: demonstration of antibodies to peripheral nerve tissue

Sera from 30 patients with acute Guillain-Barré syndrome were tested for the presence of antibodies to peripheral nerve tissue using the antiglobulin consumption test. An increased binding of IgG was observed in 15 out of 30 sera and in these sera F(ab')2 fragments prepared from IgG retained the capacity to combine with peripheral nerve tissue, suggesting an antigen-antibody interaction. The specificity for peripheral nerve tissue was demonstrated by absorption experiments. F(ab')2 fragments prepared from IgG of normal sera, however, failed to react with the tissue, suggesting a non-specific binding through the Fc part of the molecule. In sera from patients fully recovered from the Guillain-Barré syndrome and from patients with other neuropathies, no increased binding of IgG was observed.

Clinical features of the Guillain-Barré syndrome

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

Landry-Guillain-Barré-Strohl syndrome. A study of 302 cases

Three hundred and two cases of Landry-Guillain-Barré-Strohl syndrome (LGBSS) are studied and relevant literature is reviewed. The existing diagnostic criteria appear not in keeping with the histopathological and immunological findings of this condition, hence some modifications have been suggested. The role of steroids in the treatment of this disorder is critically examined, and no benefit is found to be gained from their use.

Landry-Guillain-Barré-Strohl syndrome in typhoid fever

A case is described of a 15-year-old girl who developed Landry-Guillain-Barré-Strohl Syndrome (LGBSS) on the ninth day of typhoid fever. In the absence of other known cause or association of LGBSS Salmonella typhi is believed to be aetiologically related. The patient recovered uneventfully from her neurological illness in about ten weeks from onset of symptoms.

Polyradiculoneuropathy accompanying procainamide-induced lupus erythematosus: evidence for drug-induced enhanced sensitization to peripheral nerve myelin

Factors involved in the development of an insidious polyradiculoneuropathy in association with a procainamide-induced, lupuslike syndrome were explored. A 73-year-old man with this clinical syndrome had sural nerve changes consisting of loss of large myelinated fibers with evidence of remyelination and Schwann cell proliferation. The patient's lymphocytes showed marked incorporation of tritiated thymidine when cultured with either procainamide or extracts of human peripheral nerve myelin, and there was an enhanced response with the combination. We also found that procainamide-treated rats showed acceleration of lymphocyte sensitization to peripheral nerve myelin as judged by the early development of inhibition of macrophage migration and positive skin tests to extracts of peripheral nerve myelin. These studies suggest that procainamide can enhance lymphocyte sensitization to peripheral nerve myelin and may have predisposed this individual to development of a polyradiculoneuropathy.