Infective Endocarditis Following Chicken Pox: A Rare Association

A 38-year old immunocompetent male presented to us with chicken pox complicated by development of Guillain-Barre syndrome (GBS) and left-sided native valve endocarditis due to methicillin resistant Staphylococcus aureus (MRSA). This was further complicated by embolization to various vital organs including the brain. The patient was treated with vancomycin for four weeks but did not respond to the treatment. We present this case to highlight the rare complications associated with chicken pox and the challenges faced in management of such a case.

[The most frequent causative agents of Guillain-Barre syndrome in a Mexican general hospital]

INTRODUCTION

After Zika virus outbreak and the increase in the incidence of Guillain-Barre syndrome (GBS), the causal relationship has been studied, however a full etiological correlation has not been found.

PATIENTS AND METHODS

From January 1 to December 31, 2017, patients with GBS were included. In addition to the basic serologies, enterovirus, herpes, Campylobacter, hepatitis B and C, TORCH, HIV, Brucella and Salmonella were requested.

RESULTS

Cohort of seven male patients. Five patients analyzed cerebrospinal fluid reporting normal; all of them underwent brain scan, reporting normal. Neuroconduction was performed, resulting in acute inflammatory demyelinating polyneuropathy in four cases and acute motor axonal neuropathy in one case. All received intravenous immunoglobulins, five cases had a good prognosis and two deaths. No positive cases were reported to Zika virus. A positive case was reported to dengue and another to chikungunya. Five positive cases were reported to Campylobacter. One case positive to enterovirus. Dengue + Campylobacter coinfections were reported in one case and chikungunya + Campylobacter in another case.

CONCLUSIONS

The present cohort shows that it was not possible to establish a causal relationship between GBS and Zika virus, but other viral and bacterial causal agents were identified, such as dengue, chikungunya and enterovirus, with the identification of Campylobacter cases even more remarkable.

Transverse Myelitis and Guillain-Barré Syndrome Associated with Cat-Scratch Disease, Texas, USA, 2011

We describe a case of coexisting transverse myelitis and Guillain-Barré syndrome related to infection with Bartonella henselae proteobacterium and review similar serology-proven cases. B. henselae infection might be emerging as a cause of myelitis and Guillain-Barré syndrome and should be considered as an etiologic factor in patients with such clinical presentations.

Guillain-Barré syndrome, transverse myelitis and infectious diseases

Guillain-Barré syndrome (GBS) and transverse myelitis (TM) both represent immunologically mediated polyneuropathies of major clinical importance. Both are thought to have a genetic predisposition, but as of yet no specific genetic risk loci have been clearly defined. Both are considered autoimmune, but again the etiologies remain enigmatic. Both may be induced via molecular mimicry, particularly from infectious agents and vaccines, but clearly host factor and co-founding host responses will modulate disease susceptibility and natural history. GBS is an acute inflammatory immune-mediated polyradiculoneuropathy characterized by tingling, progressive weakness, autonomic dysfunction, and pain. Immune injury specifically takes place at the myelin sheath and related Schwann-cell components in acute inflammatory demyelinating polyneuropathy, whereas in acute motor axonal neuropathy membranes on the nerve axon (the axolemma) are the primary target for immune-related injury. Outbreaks of GBS have been reported, most frequently related to Campylobacter jejuni infection, however, other agents such as Zika Virus have been strongly associated. Patients with GBS related to infections frequently produce antibodies against human peripheral nerve gangliosides. In contrast, TM is an inflammatory disorder characterized by acute or subacute motor, sensory, and autonomic spinal cord dysfunction. There is interruption of ascending and descending neuroanatomical pathways on the transverse plane of the spinal cord similar to GBS. It has been suggested to be triggered by infectious agents and molecular mimicry. In this review, we will focus on the putative role of infectious agents as triggering factors of GBS and TM.

Matrix metalloproteinases-2 and -9 in Campylobacter jejuni-induced paralytic neuropathy resembling Guillain-Barré syndrome in chickens

Inflammation in Guillain-Barré syndrome (GBS) is manifested by changes in matrix metalloproteinase (MMP) and pro-inflammatory cytokine expression. We investigated the expression of MMP-2, -9 and TNF-α and correlated it with pathological changes in sciatic nerve tissue from Campylobacter jejuni-induced chicken model for GBS. Campylobacter jejuni and placebo were fed to chickens and assessed for disease symptoms. Sciatic nerves were examined by histopathology and immunohistochemistry. Expressions of MMPs and TNF-α, were determined by real-time PCR, and activities of MMPs by zymography. Diarrhea developed in 73.3% chickens after infection and 60.0% of them developed GBS like neuropathy. Pathology in sciatic nerves showed perinodal and/or patchy demyelination, perivascular focal lymphocytic infiltration and myelin swelling on 10th- 20th post infection day (PID). MMP-2, -9 and TNF-α were up-regulated in progressive phase of the disease. Enhanced MMP-2, -9 and TNF-α production in progressive phase correlated with sciatic nerve pathology in C. jejuni-induced GBS chicken model.

Transplanted human fecal microbiota enhanced Guillain Barré syndrome autoantibody responses after Campylobacter jejuni infection in C57BL/6 mice

BACKGROUND

Campylobacter jejuni is the leading antecedent infection to the autoimmune neuropathy Guillain-Barré syndrome (GBS), which is accompanied by an autoimmune anti-ganglioside antibody attack on peripheral nerves. Previously, we showed that contrasting immune responses mediate C. jejuni induced colitis and autoimmunity in interleukin-10 (IL-10)-deficient mice, dependent upon the infecting strain. Strains from colitis patients elicited T helper 1 (T_H1)-dependent inflammatory responses while strains from GBS patients elicited T_H2-dependent autoantibody production. Both syndromes were exacerbated by antibiotic depletion of the microbiota, but other factors controlling susceptibility to GBS are unknown.

METHODS

Using 16S rRNA gene high-throughput sequencing, we examined whether structure of the gut microbial community alters host (1) gastrointestinal inflammation or (2) anti-ganglioside antibody responses after infection with C. jejuni strains from colitis or GBS patients. We compared these responses in C57BL/6 mice with either (1) stable human gut microbiota (^Humicrobiota) transplants or (2) conventional mouse microbiota (^Convmicrobiota).

RESULTS

Inoculating germ-free C57BL/6 wild-type (WT) mice with a mixed human fecal slurry provided a murine model that stably passed its microbiota over >20 generations. Mice were housed in specific pathogen-free (SPF) facilities, while extra precautions of having caretakers wear sterile garb along with limited access ensured that no mouse pathogens were acquired. ^Humicrobiota conferred many changes upon the WT model in contrast to previous results, which showed only colonization with no disease after C. jejuni challenge. When compared to ^Convmicrobiota mice for susceptibility to C. jejuni enteric or GBS patient strains, infected ^Humicrobiota mice had (1) 10-100 fold increases in C. jejuni colonization of both strains, (2) pathologic change in draining lymph nodes but only mild changes in colon or cecal lamina propria, (3) significantly lower Th1/Th17-dependent anti-C. jejuni responses, (4) significantly higher IL-4 responses at 5 but not 7 weeks post infection (PI), (5) significantly higher Th2-dependent anti-C. jejuni responses, and (6) significantly elevated anti-ganglioside autoantibodies after C. jejuni infection. These responses in ^Humicrobiota mice were correlated with a dominant Bacteroidetes and Firmicutes microbiota.

CONCLUSIONS

These data demonstrate that ^Humicrobiota altered host-pathogen interactions in infected mice, increasing colonization and Th-2 and autoimmune responses in a C. jejuni strain-dependent manner. Thus, microbiota composition is another factor controlling susceptibility to GBS.

Association between acute motor axonal neuropathy and septic shock due to Acinetobacter baumannii

In this report, we describe a case of acute motoral axonal neuropathy (AMAN) following septic shock due to Acinetobacter baumannii. The aetiology of AMAN is still not fully clarified. An association with a potential infection by Campylobacter jejuni, resulting in stimulation of autoimmune response against gangliosides mediated by a phenomenon of molecular mimicry, is believed to play a major role. Since the lipopolysaccharide of A. baumannii has a structure that is similar to that of C. jejuni, we hypothesise that the infection by A. baumannii in our patient may have had a pathogenic role in the development of the neurological picture via a mechanism of molecular mimicry.

Acute small fiber neuropathy following Mycoplasma infection: a rare variant of Guillain-Barré syndrome

Guillain-Barré syndrome (GBS) is a well-described condition involving the peripheral nervous system. The most well-known form of this disease is acute inflammatory demyelinating polyradiculoneuropathy. Among the different variants of GBS described in the literature, the sensory variant is scantily recognized. There has been a recent attempt to classify the sensory variants of the GBS and bring more objectivity to this diagnostic paradigm. We report a rare sensory variant of GBS presenting with isolated small nerve fiber involvement peripherally in the limbs and associated facial nerve palsy in a patient who had clinical and serological evidence of a preceding Mycoplasma pneumoniae infection. The symptoms resolved gradually with intravenous immunoglobulin therapy. This case adds to the growing literature of the rare form of acute small fiber neuropathy and GBS variants.

The demyelination neurophysiological criteria can be misleading in Campylobacter jejuni-related Guillain-Barré syndrome

OBJECTIVE

The exclusive association of Campylobacter jejuni infection with the axonal variant of Guillain-Barré syndrome (GBS) is debatable. The current study aims to elucidate the GBS subtypes of patients with an antecedent C. jejuni infection.

METHODS

Nerve conduction study results of 73 patients with GBS were reviewed. Patients were defined as having a recent C. jejuni infection when there was a positive stool culture or serological evidence of C. jejuni in the presence of preceding diarrhea.

RESULTS

A total of 23 patients had evidence of a recent C. jejuni infection. At the early stage, patients were classified as AMAN (n=9; 39%), AIDP (n=3; 13%) or equivocal (n=9) using existing electrophysiological criteria. Prolonged distal latencies and conduction slowing that were seen in 11 patients rapidly normalized within 3 weeks in seven, whereas four had minor abnormalities throughout the course. Subsequently, all patients showed either acute motor axonal neuropathy pattern or reversible conduction failure.

CONCLUSION

Serial neurophysiology suggests that C. jejuni infections are exclusive to axonal GBS.

SIGNIFICANCE

Our findings suggest that AMAN can demonstrate the full complement of demyelinating features at the early stages of disease.

Guillain-Barré syndrome-related Campylobacter jejuni in Bangladesh: ganglioside mimicry and cross-reactive antibodies

Background

Campylobacter jejuni is the predominant antecedent infection in Guillain-Barré syndrome (GBS). Molecular mimicry and cross-reactive immune responses to C. jejuni lipo-oligosaccharides (LOS) precipitate the development of GBS, although this mechanism has not been established in patients from developing countries. We determined the carbohydrate mimicry between C. jejuni LOS and gangliosides, and the cross-reactive antibody response in patients with GBS in Bangladesh.

Methodology

Sera from 97 GBS patients, and 120 neurological and family controls were tested for antibody reactivity against LOS from C. jejuni isolates from GBS patients in Bangladesh (BD-07, BD-39, BD-10, BD-67 and BD-94) by enzyme-linked immunosorbent assay (ELISA). Cross-reactivity to LOS was determined by ELISA. The LOS outer core structures of C. jejuni strains associated with GBS/MFS were determined by mass spectrometry.

Principle Findings

IgG antibodies to LOS from C. jejuni BD-07, BD-39, BD-10, and BD-67 IgG antibodies were found in serum from 56%, 58%, 14% and 15% of GBS patients respectively, as compared to very low frequency (<3%) in controls (p<0.001). Monoclonal antibodies specific for GM1 and GD1a reacted strongly with LOS from the C. jejuni strains (BD-07 and BD-39). Mass spectrometry analysis confirmed the presence of GM1 and GD1a carbohydrate mimics in the LOS from C. jejuni BD-07 and BD-39. Both BD-10 and BD-67 express the same LOS outer core, which appears to be a novel structure displaying GA2 and GD3 mimicry. Up to 90–100% of serum reactivity to gangliosides in two patients (DK-07 and DK-39) was inhibited by 50 µg/ml of LOS from the autologous C. jejuni isolates. However, patient DK-07 developed an anti-GD1a immune response while patient DK-39 developed an anti-GM1 immune response.

Conclusion

Carbohydrate mimicry between C. jejuni LOS and gangliosides, and cross-reactive serum antibody precipitate the majority of GBS cases in Bangladesh.

Avian resistance to Campylobacter jejuni colonization is associated with an intestinal immunogene expression signature identified by mRNA sequencing

Campylobacter jejuni is the most common cause of human bacterial gastroenteritis and is associated with several post-infectious manifestations, including onset of the autoimmune neuropathy Guillain-Barré syndrome, causing significant morbidity and mortality. Poorly-cooked chicken meat is the most frequent source of infection as C. jejuni colonizes the avian intestine in a commensal relationship. However, not all chickens are equally colonized and resistance seems to be genetically determined. We hypothesize that differences in immune response may contribute to variation in colonization levels between susceptible and resistant birds. Using high-throughput sequencing in an avian infection model, we investigate gene expression associated with resistance or susceptibility to colonization of the gastrointestinal tract with C. jejuni and find that gut related immune mechanisms are critical for regulating colonization. Amongst a single population of 300 4-week old chickens, there was clear segregation in levels of C. jejuni colonization 48 hours post-exposure. RNAseq analysis of caecal tissue from 14 C. jejuni-susceptible and 14 C. jejuni-resistant birds generated over 363 million short mRNA sequences which were investigated to identify 219 differentially expressed genes. Significantly higher expression of genes involved in the innate immune response, cytokine signaling, B cell and T cell activation and immunoglobulin production, as well as the renin-angiotensin system was observed in resistant birds, suggesting an early active immune response to C. jejuni. Lower expression of these genes in colonized birds suggests suppression or inhibition of a clearing immune response thus facilitating commensal colonization and generating vectors for zoonotic transmission. This study describes biological processes regulating C. jejuni colonization of the avian intestine and gives insight into the differential immune mechanisms incited in response to commensal bacteria in general within vertebrate populations. The results reported here illustrate how an exaggerated immune response may be elicited in a subset of the population, which alters host-microbe interactions and inhibits the commensal state, therefore having wider relevance with regard to inflammatory and autoimmune disease.

Guillain-Barré syndrome associated with acute hepatitis E infection

Guillain-Barré syndrome (GBS) is a neurological emergency that warrants prompt diagnosis and treatment. Occasionally, the clinical, laboratory and electrophysiological features are neither typical nor diagnostic. It requires a high index of suspicion and clinical judgement for early diagnosis and commencement of treatment in those scenarios. Some pathogens are potential triggers of this serious neurological disease, including: Campylobacter jejuni, Mycoplasma pneumoniae and cytomegalovirus. Although uncommon, hepatotrophic viruses (hepatitis A, B and C) are increasingly recognized to be triggering microbes. Here, we report a patient with unusual GBS triggered by an atypical microbe, hepatitis E virus, in a Chinese patient, via a common route of transmission in this locality.

Campylobacter jejuni DNA-binding protein from starved cells in Guillain-Barré syndrome patients

Campylobacter jejuni enteritis is frequently associated with an axonal form of Guillain-Barré syndrome (GBS) and C. jejuni DNA-binding protein from starved cells (C-Dps) induces paranodal myelin detachment and axonal degeneration through binding with sulfatide in vivo. Here we investigated the invasion of C-Dps into hosts with C. jejuni-related GBS. Our analyses of patient sera found that both C-Dps and anti-C-Dps antibodies were most commonly detected in sera from C. jejuni-related GBS patients (5/27, 14.8% and 15/24, 62.5%; respectively). These findings suggest that C-Dps invades the host and may potentially contribute to the peripheral nerve damage in C. jejuni-related GBS.

Preceding infections and anti-ganglioside antibody profiles assessed by a dot immunoassay in 306 French Guillain-Barré syndrome patients

We describe by an in-house dot immunoassay, specific anti-ganglioside and sulfatide antibodies, by comparing the results from a large group of 134 infected French GBS patients and those from 172 noninfected French GBS and 142 control groups. A recent infection was identified in 134/306 (43.8%) GBS patients: Campylobacter jejuni (24.6%) was the most common agent, followed by cytomegalovirus (12.4%), Mycoplasma pneumoniae (3.2%) and Epstein-Barr virus (1.3%). Anti-ganglioside antibodies were detected in 97/306 (31.7%) of total GBS patients, 82/134 (61.2%) of GBS patients with a recent identified infection and 15/172 (8.7%) of the patients without identified infection. According to the specificities and antibody classes, four specific IgG antibody profiles were individualised against the two major GM1 and GD1a gangliosides in motor axonal C. jejuni-associated GBS variants, against GQ1b and disialylated gangliosides in Miller Fisher syndrome and its variants. One specific IgM profile against GM2 was found in 16/38 (42%) of severe sensory demyelinating CMV-associated GBS and in 8/17 (47%) of subjects with recent CMV infection with no neurological disease. IgG or IgM antibodies to GM1 were found in 5/10 M. pneumoniae-infected patients. IgM antibodies to GM1 were observed in the control groups, 15% of the 74 patients with amyotrophic lateral sclerosis, 19% of the 51 patients with chronic inflammatory demyelinating polyneuropathy, and 9% of the 21 healthy control subjects. The fine specificity of the four IgG antibody profiles and the IgM anti-GM2 profile is closely related to the nature of the preceding infections and the pattern of clinical features.

Genomic characterization of the Guillain-Barre syndrome-associated Campylobacter jejuni ICDCCJ07001 Isolate

Campylobacter jejuni ICDCCJ07001 (HS:41, ST2993) was isolated from a Guillain-Barré syndrome (GBS) patient during a 36-case GBS outbreak triggered by C. jejuni infections in north China in 2007. Sequence analysis revealed that the ICDCCJ07001 genome consisted of 1,664,840 base pairs (bp) and one tetracycline resistance plasmid of 44,084 bp. The GC content was 59.29% and 1,579 and 37 CDSs were identified on the chromosome and plasmid, respectively. The ICDCCJ07001 genome was compared to C. jejuni subsp. jejuni strains 81-176, 81116, NCTC11168, RM1221 and C. jejuni subsp. doylei 269.97. The length and organization of ICDCCJ07001 was similar to that of NCTC11168, 81-176 and 81-116 except that CMLP1 had a reverse orientation in strain ICDCCJ07001. Comparative genomic analyses were also carried out between GBS-associated C. jejuni strains. Thirteen common genes were present in four GBS-associated strains and 9 genes mapped to the LOS cluster and the ICDCCJ07001_pTet (44 kb) plasmid was mosaic in structure. Thirty-seven predicted CDS in ICDCCJ07001_pTet were homologous to genes present in three virulence-associated plasmids in Campylobacter: 81-176_pTet, pCC31 and 81-176_pVir. Comparative analysis of virulence loci and virulence-associated genes indicated that the LOS biosynthesis loci of ICDCCJ07001 belonged to type A, previously reported to be associated with cases of GBS. The polysaccharide capsular biosynthesis (CPS) loci and the flagella modification (FM) loci of ICDCCJ07001 were similar to corresponding sequences of strain 260.94 of similar serotype as strain ICDCCJ07001. Other virulence-associated genes including cadF, peb1, jlpA, cdt and ciaB were conserved between the C. jejuni strains examined.

Characteristics of lipo-oligosaccharide loci of Campylobacter jejuni isolates associated with Guillain-Barré Syndrome from Hebei, China

Ganglioside mimicry by C.jejuni lipo-oligosaccharides (LOS) could induce the production of autoantibodies against gangliosides and the development of Guillain-Barré syndrome (GBS). The LOS biosynthesis region exhibits significant variation with different strains. Using PCR amplifications of genes from published LOS loci and sequencing the LOS biosynthesis loci, the eight GBS-associated C. jejuni strains from HeBei could be classified into four classes. The expression of sialylated LOS structures (class A) or non-sialylated LOS structures(class F, H and P) in the C. jejuni LOS is considered to be two different factors for the induction of GBS.

Comparative genotyping of Campylobacter jejuni strains from patients with Guillain-Barré syndrome in Bangladesh

BACKGROUND

Campylobacter jejuni is a common cause of acute gastroenteritis and is associated with post-infectious neuropathies such as the Guillain-Barré syndrome (GBS) and the Miller Fisher syndrome (MFS). We here present comparative genotyping of 49 C. jejuni strains from Bangladesh that were recovered from patients with enteritis or GBS. All strains were serotyped and analyzed by lipo-oligosaccharide (LOS) genotyping, amplified fragment length polymorphism (AFLP) analysis, multilocus sequence typing (MLST), and pulsed-field gel electrophoresis (PFGE).

METHODOLOGY/PRINCIPAL FINDINGS

C. jejuni HS:23 was a predominant serotype among GBS patients (50%), and no specific serotype was significantly associated with GBS compared to enteritis. PCR screening showed that 38/49 (78%) of strains could be assigned to LOS classes A, B, C, or E. The class A locus (4/7 vs 3/39; p<0.01) was significantly associated in the GBS-related strains as compared to enteritis strains. All GBS/oculomotor related strains contained the class B locus; which was also detected in 46% of control strains. Overlapping clonal groups were defined by MLST, AFLP and PFGE for strains from patients with gastroenteritis and GBS. MLST defined 22 sequence types (STs) and 7 clonal complexes including 7 STs not previously identified (ST-3742, ST-3741, ST-3743, ST-3748, ST-3968, ST-3969 and ST-3970). C. jejuni HS:23 strains from patients with GBS or enteritis were clonal and all strains belonged to ST-403 complex. Concordance between LOS class B and ST-403 complex was revealed. AFLP defined 25 different types at 90% similarity. The predominant AFLP type AF-20 coincided with the C. jejuni HS:23 and ST-403 complex.

CONCLUSION/SIGNIFICANCE

LOS genotyping, MLST, AFLP and PFGE helped to identify the HS:23 strains from GBS or enteritis patients as clonal. Overall, genotypes exclusive for enteritis or for GBS-related strains were not obtained although LOS class A was significantly associated with GBS strains. Particularly, the presence of a clonal and putative neuropathogenic C. jejuni HS:23 serotype may contribute to the high prevalence of C. jejuni related GBS in Bangladesh.

[Comparison of Cj1136, Cj1138 and Cj1139 genes among Campylobacter jejuni strains]

OBJECTIVE

By sequenceing the Cj1136, Cj1138 and Cj1139 gene of Campylobacter jejuni (C. jejuni) strains associated with Guillain-Barré Syndrome (GBS), features of Cj1136, Cj1138 and Cj1139 gene were studied. Results were compared with the C. jejuni strain NCTC11168, to find the mutations in sequence of C. jejuni which inducing GBS and their polygenetic relationship was analyzed.

METHODS

Three GBS-associated C. jejuni strains were isolated from stools of GBS patients from Hebei province who had been diagnosed as clinical AMAN pattern and electrophysiological tests were performed. After distilling and sequencing Cj1136, Cj1138 and Cj1139 genes, results were spliced and assembled into a complete sequence by the terminals overlapped with each other. Sequences of Cj1136, Cj1138 and Cj1139 genes were compared with NCTC11168, to find the mutations and gene feature.

RESULTS

The Cj1136, Cj1138 and Cj1139 gene of the three GBS- associated C. jejuni strains were composed by 1173 base pairs, 1170 base pairs, 912 base pairs respectively. The alignment with the related sequence of NCTC11168 showed that there were two same mutations in the Cj1138 gene of the three C. jejuni stains. Data from phylogenetic analysis demonstrated that the three C. jejuni strains were genetically closed to NCTC11168, with the biggest phylogenetic distance between the three of them as 2.1%.

CONCLUSION

When compared with NCTC11168 the Cj1138 gene of the three GBS-associated C. jejuni strains had the same mutations which might be related to the development of GBS. Relation between the variation and GBS-pathogenesis remained to be confirmed. The mutations found in the three C. jejuni strains established the foundation for exploring the biological characteristics of GBS-associated C. jejuni strains and demonstrated that the GBSassociated C. jejuni strains of Hebei province having its regional features.

Campylobacter infection as a trigger for Guillain-Barré syndrome in Egypt

BACKGROUND

Most studies of Campylobacter infection triggering Guillain-Barré Syndrome (GBS) are conducted in western nations were Campylobacter infection and immunity is relatively rare. In this study, we explored Campylobacter infections, Campylobacter serotypes, autoantibodies to gangliosides, and GBS in Egypt, a country where Campylobacter exposure is common.

METHODS

GBS cases (n = 133) were compared to age- and hospital-matched patient controls (n = 374). A nerve conduction study was performed on cases and a clinical history, serum sample, and stool specimen obtained for all subjects.

RESULTS

Most (63.3%) cases were demyelinating type; median age four years. Cases were more likely than controls to have diarrhea (29.5% vs. 22.5%, Adjusted Odds Ratio (ORa) = 1.69, P = 0.03), to have higher geometric mean IgM anti-Campylobacter antibody titers (8.18 vs. 7.25 P<0.001), and to produce antiganglioside antibodies (e.g., anti-Gd1a, 35.3 vs. 11.5, ORa = 4.39, P<0.0001). Of 26 Penner:Lior Campylobacter serotypes isolated, only one (41:27, C. jejuni, P = 0.02) was associated with GBS.

CONCLUSIONS

Unlike results from western nations, data suggested that GBS cases were primarily in the young and cases and many controls had a history of infection to a variety of Campylobacter serotypes. Still, the higher rates of diarrhea and greater antibody production against Campylobacter and gangliosides in GBS patients were consistent with findings from western countries.

Scrub typhus as a possible aetiology of Guillain-Barré syndrome: two cases

Neurological complications of scrub typhus are reported to be rare. Peripheral nervous system involvement has been reported in only one case. We present two cases of Guillan-Barré syndrome (GBS) associated with scrub typhus. In both cases, the findings of an elevated indirect immunofluorescent antibody titer for Orientia tsutsugamushi and nerve conduction study showing sensory-motor polyneuropathy, have led us to believe that scrub typhus could be one of the antecedent illnesses associated with GBS.

[Campylobacter jejuni infection in patient with Guillain-Barré syndrome: a case report]

The Guillain-Barré syndrome is an acute inflammatory polineuropathy; it's frequency is established at the level of 1,3 cases/ 100 000 persons/ year. The main etiological factors concerned with the GBS occurrence are: Campylobacter jejuni, cytomegalovirus, Epstein-Barre virus, Mycoplasma pneumoniae. The authors present a case of the 15 years old boy with the clinical features of acute motor axonal polineuropathy and confirmed C. jejuni infection. Identification of C. jejuni isolate was based on colony morphology on CCDA plate (OXOID), characteristic motility, catalase, oxidase, hippurate hydrolysis and acetate hydrolysis. The identity of C. jejuni was also confirmed by a specific PCR. According to the authors' knowledge this is the first case of a patient with GBS with confirmed C. jejuni infection reported from Poland.

Guillain-Barré syndrome associated with scrub typhus

We report a 42-y-old female with Guillain-Barré syndrome (GBS) who presented with scrub typhus for a duration of 2 weeks. Subsequently, ascending paralysis and facial diplegia developed. GBS was confirmed with nerve conduction studies and cerebrospinal fluid examinations. After administration of intravenous immunoglobulin, symptoms gradually disappeared.

Patterns of Guillain-Barre syndrome in children: results from a Mexican population

BACKGROUND

Guillain-Barré syndrome (GBS) is an acute, immune-mediated flaccid paralysis frequently associated with Campylobacter infection. Of two predominant GBS subtypes, a demyelinating subtype (acute inflammatory demyelinative polyneuropathy [AIDP]) predominates in the United States and Europe, and axonal subtype (acute motor axonal neuropathy [AMAN]) is the predominant form in China. Previous clinical studies suggested that AMAN also occurs in Mexican children. The purpose of this study was to describe the subtypes of GBS in children from Mexico City.

METHODS

We prospectively studied 121 children admitted to two pediatric hospitals in Mexico City from 1996 to 2002. Clinical histories were obtained, electrophysiologic studies were performed to determine GBS subtype, and microbiologic studies were performed.

RESULTS

Of the 121 children, 46 had AMAN and 32 had AIDP. The male to female ratio was 1.3 for AMAN cases (mean age = 6.3) and 3.0 for AIDP cases (mean age = 7.0). There was a strong seasonal distribution of AMAN cases in July to September. Children with AMAN, but not AIDP, had worsening of illness during hospitalization as judged by peak severity scores. Vomiting was more likely in AIDP (28.1%) vs AMAN (6.5%) (p = 0.012) and diarrhea was more common in AMAN (32.6%) than AIDP (12.5%) (p = 0.06). IgG anti-GM1 antibody titers were higher in patients with AMAN vs AIDP (p = 0.067). Anti-GD1a antibodies were equally present in both groups. Anti GQ1b titers were higher in AMAN vs AIDP (p = 0.009). Campylobacter antibody responses were positive in 44.1% of patients with AMAN and 37.0% of patients with AIDP. Twenty patients (14 = AMAN, 6 = AIDP) had positive stool cultures for C jejuni. Two serotypes, HS:19 and HS:41, accounted for 6 of 10 Campylobacter isolates available for serotyping from these cases.

CONCLUSIONS

This study confirms that acute motor axonal neuropathy is an important Guillain-Barré syndrome subtype in Mexican children, is associated with diarrhea, and occurs seasonally.

Validation of an ELISA for the diagnosis of recent Campylobacter infections in Guillain–Barré and reactive arthritis patients

Weeks or months following Campylobacter infection, a small proportion of infected individuals develop Guillain-Barré syndrome (GBS) or reactive arthritis (ReA). Stool culture for Campylobacter is often negative in these patients, and serology is therefore the method of choice for diagnosing a recent infection with Campylobacter. This study developed a capture ELISA system to detect anti-Campylobacter IgA and IgM antibodies indicative of a recent infection. The sensitivity of the assay was 82.0% in uncomplicated Campylobacter enteritis patients, 96.2% in GBS patients who were culture-positive for Campylobacter, and 93.1% in culture-positive ReA patients, with a specificity of 93.0%. The assay allows identification of Campylobacter infection in patients with post-infectious neurological and rheumatological complications.

Influenza, Campylobacter and Mycoplasma infections, and hospital admissions for Guillain-Barré syndrome, England

TOC Summary line: Campylobacter, Mycoplasma pneumoniae, and influenza (or influenza vaccination) act as infectious triggers for Guillain-Barré syndrome.

Guillain-Barré syndrome (GBS) is the most common cause of acute flaccid paralysis in polio-free regions. Considerable evidence links Campylobacter infection with GBS, but evidence that implicates other pathogens as triggers remains scarce. We conducted a time-series analysis to investigate short-term correlations between weekly laboratory-confirmed reports of putative triggering pathogens and weekly hospitalizations for GBS in England from 1993 through 2002. We found a positive association between the numbers of reports of laboratory-confirmed influenza A in any given week and GBS hospitalizations in the same week. Different pathogens may trigger GBS in persons of different ages; among those <35 years, numbers of weekly GBS hospitalizations were associated with weekly Campylobacter and Mycoplasma pneumoniae reports, whereas among those >35 years, positive associations were with influenza. Further studies should estimate the relative contribution of different pathogens to GBS incidence, overall and by age group, and determine whether influenza is a real trigger for GBS or a marker for influenza vaccination.

Guillain-Barré syndrome and preceding infection with campylobacter, influenza and Epstein-Barr virus in the general practice research database

Background

A number of infectious agents have previously been suggested as risk factors for the development of Guillain-Barré syndrome (GBS), but robust epidemiologic evidence for these associations is lacking.

Methods and Findings

We conducted a nested case-control study using data from the United Kingdom General Practice Research Database between 1991 and 2001. Controls were matched to cases on general practice clinic, sex, year of birth and date of outcome diagnosis in their matched case. We found positive associations between GBS and infection with Campylobacter, Epstein-Barr virus and influenza-like illness in the previous two months, as well as evidence of a protective effect of influenza vaccination. After correction for under-ascertainment of Campylobacter infection, the excess risk of GBS following Campylobacter enteritis was 60-fold and 20% of GBS cases were attributable to this pathogen.

Conclusions

Our findings indicate a far greater excess risk of GBS among Campylobacter enteritis patients than previously reported by retrospective serological studies. In addition, they confirm previously suggested associations between infection due to Epstein-Barr virus infection and influenza-like illness and GBS. Finally, we report evidence of a protective effect of influenza vaccination on GBS risk, which may be mediated through protection against influenza disease, or result from a lower likelihood of vaccination among those with recent infection. Cohort studies of GBS incidence in this population would help to clarify the burden of GBS due to influenza, and any potential protective effect of influenza vaccination.

Structural characterization of Campylobacter jejuni lipooligosaccharide outer cores associated with Guillain-Barre and Miller Fisher syndromes

Molecular mimicry between lipooligosaccharides (LOS) of Campylobacter jejuni and gangliosides in peripheral nerves plays a crucial role in the pathogenesis of C. jejuni-related Guillain-Barré syndrome (GBS). We have analyzed the LOS outer core structures of 26 C. jejuni strains associated with GBS and its variant, Miller Fisher syndrome (MFS), by capillary electrophoresis coupled with electrospray ionization mass spectrometry. Sixteen out of 22 (73%) GBS-associated and all 4 (100%) MFS-associated strains expressed LOS with ganglioside mimics. GM1a was the most prevalent ganglioside mimic in GBS-associated strains (10/22, 45%), and in eight of these strains, GM1a was found in combination with GD1a mimics. All seven strains isolated from patients with ophthalmoplegia (GBS or MFS) expressed disialylated (GD3 or GD1c) mimics. Three out of 22 GBS-associated strains (14%) did not express sialylated ganglioside mimics because their LOS locus lacked the genes necessary for sialylation. Three other strains (14%) did not express ganglioside mimics because of frameshift mutations in either the cstII sialyltransferase gene or the cgtB galactosyltransferase gene. It is not possible to determine if these mutations were already present during C. jejuni infection. This is the first report in which mass spectrometry combined with DNA sequence data were used to infer the LOS outer core structures of a large number of neuropathy-associated C. jejuni strains. We conclude that molecular mimicry between gangliosides and C. jejuni LOS is the presumable pathogenic mechanism in most cases of C. jejuni-related GBS. However, our findings suggest that in some cases, other mechanisms may play a role. Further examination of the disease etiology in these patients is mandatory.

Bacterial infections in Guillain-Barré and Fisher syndromes

PURPOSE OF REVIEW

Progress has been made in our understanding of Guillain-Barré syndrome, especially in identifying the Campylobacter jejuni genes responsible for the development of clinical features.

RECENT FINDINGS

C. jejuni is grouped into several classes based on the organization of lipo-oligosaccharide biosynthesis genes. A specific class carrying a sialyltransferase gene (cst-II) is associated with the development of Guillain-Barré syndrome, which is essential for the biosynthesis of ganglioside-like lipo-oligosaccharides. The class of C. jejuni expressed both GM1-like and GD1a-like lipo-oligosaccharides, which could induce the production of autoantibodies to GM1, to GD1a or to the GM1/GD1a complex, possibly increasing the risk of development. C. jejuni sialyltransferase (Cst-II) consists of 291 amino acids, and the 51st amino acid determines its enzymatic activity. Strains with cst-II (Thr51) expressed GM1-like or GD1a-like lipo-oligosaccharide whereas strains with cst-II (Asn51) expressed GT1a-like or GD1c-like lipo-oligosaccharide. Patients infected with the cst-II (Thr51) strains had anti-GM1 or anti-GD1a IgG antibodies, and showed limb weakness. Patients infected with the cst-II (Asn51) strains had anti-GQ1b IgG antibodies, and showed ophthalmoplegia and ataxia.

SUMMARY

The cst-II gene is responsible for the development of Guillain-Barré and Fisher syndromes, and the polymorphism (Thr/Asn51) determines which syndrome develops after C. jejuni enteritis.

A case of Guillain-Barrè syndrome following Staphylococcus aureus endocarditis

Guillain-Barrè syndrome (GBS) is the most important cause of acute neuromuscular paralysis in western countries and it is preceded in almost all cases by an infectious disease such as Campylobacter Jejuni or Cytomegalovirus. However, GBS associated with previous bacterial endocarditis is very rare. We report the case of a 74-year-old man with GBS following Staphylococcus Aureus endocarditis affecting aortic valve. Although the absolute incidence of GBS is low, the present case stresses the need to consider GBS in patients developing neurological symptoms following any infectious illness, such as endocarditis, and highlights the challenging problem of rehabilitation and surgical management in these patients.

Relationship of bacterial strains to clinical syndromes of Campylobacter-associated neuropathies

BACKGROUND

Clinical and serologic studies suggest that Guillain-Barré syndrome (GBS) and atypical GBS with preserved muscle stretch reflexes (MSRs) form a continuous spectrum as well as do Fisher syndrome (FS), FS/GBS overlap, Bickerstaff brainstem encephalitis (BBE), BBE/GBS overlap, acute ophthalmoparesis (AO), ataxic GBS, and acute oropharyngeal palsy.

OBJECTIVE

To clarify the spectrum of neurologic disorders that occur subsequent to Campylobacter jejuni enteritis.

METHODS

We recruited patients with various neurologic conditions and from whom C jejuni was isolated. Bacterial features were investigated.

RESULTS

Diagnoses for the patients from whom C jejuni was isolated were GBS (n = 90), FS (n = 22), MSR-preserved GBS (n = 10), FS/GBS (n = 6), BBE (n = 1), BBE/GBS (n = 2), AO (n = 3), ataxic GBS (n = 1), and acute oropharyngeal palsy (n = 3). Isolates from MSR-preserved GBS were similar to those of GBS in serotype (HS:19), genotype (lipo-oligosaccharide [LOS] locus class A or B, cst-II genotype [Thr51]), and GM1 or GD1a epitope expression on LOS. FS/GBS overlap, BBE, BBE/GBS overlap, AO, ataxic GBS, and acute oropharyngeal palsy isolates were similar to those of FS in serotype (HS:2 or HS:4-complex), genotype (LOS locus class A or B, cst-II genotype [Asn51]), and GQ1b epitope expression on LOS.

CONCLUSIONS

The bacterial findings support the proposal that Guillain-Barré syndrome (GBS) and muscle stretch reflex-preserved GBS comprise a continuous spectrum as well as do Fisher syndrome (FS), FS/GBS overlap, Bickerstaff brainstem encephalitis (BBE), BBE/GBS overlap, acute ophthalmoparesis, ataxic GBS, and acute oropharyngeal palsy.

Infections and vaccinations preceding childhood Guillain-Barré syndrome: a prospective study

INTRODUCTION

We performed a prospective, multicentre study in children with Guillain-Barré syndrome (GBS), diagnosed according to international criteria, to investigate the frequency and aetiology of antecedent diseases. All infections and vaccinations occurring within a 6-week period prior to the onset of GBS were documented.

MATERIALS AND METHODS

Stool cultures, standardised serological investigations and PCR analyses for 24 different infective agents were performed. Serological findings were regarded as significant if specific immunoglobulin (Ig)M or IgA antibodies were detected, if the IgM enzyme immunoassay or immunfluorescence assay findings were confirmed by immunoblot, if complement fixation test titres rose fourfold or if geometric titres were more than threefold higher than in uninfected control persons. Ninety-five children with GBS were included in the study over a 40-month period. Preceding events were reported in 82%.

RESULTS

Microbiological studies carried out on 84 patients resulted in a probable diagnosis in 46 (55%). Coxsackieviruses (15%), Chlamydia pneumoniae (8%), cytomegalovirus (7%) and Mycoplasma pneumoniae (7%) were the most frequently involved agents. Serological evidence of a Campylobacter jejuni infection was found in six patients (7%). Eight children had been vaccinated during the 6 weeks preceding the onset of GBS; in six of these children concomitant infectious diseases were reported, and in one child the time between vaccination and GBS was extremely short.

CONCLUSION

We conclude that, in contrast to adults, Campylobacter spp. does not seem to play a major role in childhood GBS in German-speaking countries. The aetiology of antecedent diseases is distributed over a wide spectrum of paediatric infectious diseases. Most of the children who had been vaccinated showed concomitant infectious diseases, thus obscuring the causative role for GBS.

Ganglioside mimicry as a cause of Guillain-Barré syndrome

Guillain-Barré syndrome (GBS), characterized by acute progressive limb weakness and areflexia, is the prototype of postinfectious autoimmune diseases. Campylobacter jejuni is the most frequently identified agent of infection in GBS patients, often preceding acute motor axonal neuropathy (AMAN), a variant of GBS. Anti-GM1, anti-GM1b, anti-GD1a, and anti-GalNAc-GD1a IgG antibodies are associated with AMAN. Carbohydrate mimicry [Galbeta1-3GalNAcbeta1-4(NeuAcalpha2-3)Galbeta1-] was seen between the lipo-oligosaccharide of C. jejuni isolated from an AMAN patient and human GM1 ganglioside. Sensitization with the lipo-oligosaccharide of C. jejuni induces AMAN in rabbits as does sensitization with GM1 ganglioside. Paralyzed rabbits have pathological changes in their peripheral nerves identical to changes seen in human GBS. C. jejuni infection may induce anti-ganglioside antibodies by molecular mimicry, eliciting AMAN. This is the first verification of the causative mechanism of molecular mimicry in an autoimmune disease. To express ganglioside mimics, C. jejuni requires specific gene combinations that function in sialic acid biosynthesis or transfer. The knockout mutants of these landmark genes of GBS show reduced reactivity with GBS patients' sera, and fail to induce an anti-ganglioside antibody response in mice. These genes are crucial for the induction of neuropathogenic cross-reactive antibodies. An approach for evaluating intravenous immune globulin, a treatment for GBS, based on our animal model of AMAN is also discussed in this review, and recent advances made in this field are described.

Guillain-Barré syndrome, greater Paris area

We studied 263 cases of Guillain-Barré syndrome from 1996 to 2001, 40% of which were associated with a known causative agent, mainly Campylobacter jejuni (22%) or cytomegalovirus (15%). The cases with no known agent (60%) peaked in winter, and half were preceded by respiratory infection, influenza-like syndrome, or gastrointestinal illness.

Guillain-Barré syndrome: association with Campylobacter jejuni and Mycoplasma pneumoniae infections in India

BACKGROUND

Guillain-Barré syndrome is the most common cause of acute neuromuscular paralysis and is considered a post-infectious disease.

METHODS

Twenty patients with Guillain-Barré syndrome admitted to the Neurosciences Centre at the All India Institute of Medical Sciences from November 1997 to August 1998 were investigated for evidence of antecedent infections. This case-control study included 2 controls for each patient, one a household control and the other an age- and sex-matched hospital control suffering from a neurological illness other than Guillain-Barré syndrome. Evidence of recent Campylobacter jejuni infection was investigated by culture and serology, and for Mycoplasma pneumoniae by serology.

RESULTS

There was evidence of recent C. jejuni infection in 35% of the patients compared with 25% of household controls and none of the hospital controls. M. pneumoniae infection was seen in 50% of patients compared with 25% of household controls and 15% of hospital controls. About one-third of the patients (30%) had evidence of both infections. The association of both infections in patients was found to be statistically significant as compared to hospital controls.

CONCLUSION

C. jejuni and M. pneumoniae may be important antecedent illnesses in patients with Guillain-Barré syndrome in India.

Experimental axonopathy induced by immunization with Campylobacter jejuni lipopolysaccharide from a patient with Guillain-Barré syndrome

New Zealand white rabbits were immunized with a lipopolysaccharide (LPS) extracted from a Campylobacter jejuni HS:19 strain isolated from a GBS patient expressing GM1 and GD1a-like epitopes, Freund's adjuvant (group I) and Freund's adjuvant plus keyhole lympet hemocyanin (KLH) (group II). Both groups showed high titers of anti-LPS and anti-GM1 and lower titers of anti-GD1b and anti-GD1a antibodies. Weakness and axonal degeneration in sciatic nerves was detected in 1/11 of group I and 6/7 of group II. This model replicates, at least in part, the pathogenetic process hypothesized in the human axonal GBS with antiganglioside antibodies post C. jejuni infection and indicates that KLH plays an additional role in neuropathy induction.

Carbohydrate mimicry of Campylobacter jejuni lipooligosaccharide is critical for the induction of anti-GM1 antibody and neuropathy

The expression of ganglioside-mimicking structures of Campylobacter jejuni lipooligosaccharides (LOS) is considered essential for the induction of antiganglioside antibodies that lead to Guillain-Barré syndrome (GBS). The galE gene in C. jejuni is involved in the biosynthesis of the LOS outer-core oligosaccharide structures. We have demonstrated that the C. jejuni HB9313 (HS:19) parental strain expresses a LOS structure containing GM1-like epitopes, and the C. jejuni knockout mutant of the galE gene expresses a truncated LOS structure without GM1-like epitopes. To clarify whether the ganglioside-like structures in Campylobacteri LOS are crucial for induction of antiganglioside antibody responses and neuropathy, we performed immunization experiments in guinea pig models using the parental strain HB9313 and its galE mutant derivative. The anti-GM1 IgG antibody responses in immunized animals were measured by enzyme-linked immunosorbent assay. Sciatic nerve specimens were evaluated pathologically. High levels of the anti-GM1 IgG antibody were induced in guinea pigs immunized with HB9313, but not in those immunized with the galE mutant. The mean percentage of abnormality of sciatic-nerve teased fibers from animals sensitized with C. jejuni HB9313 was significantly higher than from animals immunized with the galE mutant. Furthermore, significant changes were found in semithin sections of the sciatic nerve from animals inoculated with C. jejuni HB9313. The major pathological finding was axonal degeneration; no significant morphological findings, except for occasional demyelination, were observed in animals immunized with the galE mutant. These results indicate that ganglioside-mimicry structures in C. jejuni LOS are necessary for induction of antiganglioside antibody response and neuropathy.

Identification of DNA sequence variation in Campylobacter jejuni strains associated with the Guillain-Barré syndrome by high-throughput AFLP analysis

BACKGROUND

Campylobacter jejuni is the predominant cause of antecedent infection in post-infectious neuropathies such as the Guillain-Barré (GBS) and Miller Fisher syndromes (MFS). GBS and MFS are probably induced by molecular mimicry between human gangliosides and bacterial lipo-oligosaccharides (LOS). This study describes a new C. jejuni-specific high-throughput AFLP (htAFLP) approach for detection and identification of DNA polymorphism, in general, and of putative GBS/MFS-markers, in particular.

RESULTS

We compared 6 different isolates of the "genome strain" NCTC 11168 obtained from different laboratories. HtAFLP analysis generated approximately 3000 markers per stain, 19 of which were polymorphic. The DNA polymorphisms could not be confirmed by PCR-RFLP analysis, suggesting a baseline level of 0.6% AFLP artefacts. Comparison of NCTC 11168 with 4 GBS-associated strains revealed 23 potentially GBS-specific markers, 17 of which were identified by DNA sequencing. A collection of 27 GBS/MFS-associated and 17 enteritis control strains was analyzed with PCR-RFLP tests based on 11 of these markers. We identified 3 markers, located in the LOS biosynthesis genes cj1136, cj1138 and cj1139c, that were significantly associated with GBS (P = 0.024, P = 0.047 and P < 0.001, respectively). HtAFLP analysis of 13 highly clonal South African GBS/MFS-associated and enteritis control strains did not reveal GBS-specific markers.

CONCLUSION

This study shows that bacterial GBS markers are limited in number and located in the LOS biosynthesis genes, which corroborates the current consensus that LOS mimicry may be the prime etiologic determinant of GBS. Furthermore, our results demonstrate that htAFLP, with its high reproducibility and resolution, is an effective technique for the detection and subsequent identification of putative bacterial disease markers.

Prevalence of four virulence genes in Campylobacter jejuni determined by PCR and sequence analysis

INTRODUCTION

The presence of four virulence genes (racR, wlaN, cgtB, virB11) in 356 Campylobacter jejuni strains isolated from confirmed clinical cases was examined by PCR and sequence analysis. The investigated genes were chosen on the basis of their variation in prevalence.

METHODS

The virulence genes were detected by PCR and the amplified products were submitted for sequence analysis.

RESULTS

The gene with the highest prevalence was racR (87.08%). virB was present in only 1.69% of the C. jejuni strains, and wlaN and cgtB were detected in 16.01% and 24.44%, respectively. Five strains associated with Guillain-Barré syndrome and Miller-Fischer syndrome out of the total of 356 (1.40%) were positive for cgtB.

CONCLUSION

Our findings suggest that racR may encode factors necessary for bacterial pathogenicity in humans, while the roles of the other three genes remain ambiguous.

[Antibodies to ganglioside GM1 and Campylobacter jejuni in patients with Guillain-Barré syndrome]

Guillain-Barré syndrome (GBS) is an acute immune mediated neuropathy, polyradiculoneuritis, characterized by rapid onset of symmetric extremity muscle paralysis, areflexia and albuminocytological dissociation in the cerebrospinal fluid (CSF). Recently, the heterogeneity of GBS has been noticed with definition of several GBS variants. The axonal GBS associated with anti-GM1 antibodies is the most important variant with the specific role of Campylobacterjejuni (CJ) in the induction of the disease. The role of our study was to determine the frequency of antecedent infection with CJ in the population of our patients with GBS, the association with anti-GM1 antibodies and the distribution of these antibodies within clinical forms of the disease. The diagnosis of GBS has been established in 17 patients according to clinical, electrophysiological and laboratory (CSF) criteria. The serum antibodies to 63 kDa flagellar protein isolated from CJ serotype 0:19 were determined by ELISA and Western blot and serum anti-GM1 antibodies by ELISA. In relation to the disability score two patients were ambulatory, five were ambulatory with support, seven were bedridden and two patients needed respirator. Five (29%) patients had pure motor, while 12 (71%) had sensorimotor GBS. The cranial nerves were involved in 11 (65%) and 9 (53%) patients had autonomic dysfunction. Electromyoneurography showed primary axonal, predominantly motor neuropathy in 6 (35%) and demyelinating sensorimotor neuropathy in 11 (65%) patients. The CSF protein content ranged from 0.47 to 3.88 g/L. The antecedent infection with CJ was shown by serum antibodies to CJ flagellar protein in 12 (71%) patients. Fifteen (88%) patients had IgG anti-GM1 antibodies. Twelve (71%) patients had both antibodies. In relation to the clinical form, anti-CJ antibodies were found in 8 (73%) out of 11 patients with demyelinating GBS and in 4 (66.6%) out of 6 patients with axonal GBS. The high titer of anti-GM1 antibodies was found in all patients (100%) with axonal and in 9 (82%) out of 11 patients with demyelinating GBS. The association of IgG anti-CJ and IgG anti-GM1 antibodies was found in 4 (66.6%) out of 6 patients with axonal and in 8 (73%) out of 11 patients with demyelinating GBS. The main features of our patients with GBS were high frequency of antecedent infection with CJ, unusually frequent association with anti-GM1 antibodies, and equally frequent association of anti-CJ and anti-GM1 antibodies in both, axonal and demyelinating GBS.

Ganglioside mimicry as a cause of Guillain-Barré syndrome

PURPOSE OF REVIEW

Campylobacter jejuni is the most frequent agent of antecedent infection in an axonal variant of Guillain-Barré syndrome, acute motor axonal neuropathy, and anti-GM1 or anti-GD1a IgG antibody is also associated with acute motor axonal neuropathy. Molecular mimicry has been found between human GM1 ganglioside and the lipo-oligosaccharide of C. jejuni isolated from an acute motor axonal neuropathy patient. Progress has been made in Guillain-Barré syndrome research, especially on acute motor axonal neuropathy subsequent to C. jejuni enteritis.

RECENT FINDINGS

Sensitization of rabbits with C. jejuni lipo-oligosaccharide, as well as GM1, induced the production of anti-GM1 IgG antibody, and the subsequent development of acute flaccid paralysis. Pathological changes in rabbit peripheral nerves were identical to those seen in human acute motor axonal neuropathy. These findings provide conclusive evidence that molecular mimicry is a cause of human autoimmune disease. Ganglioside-like lipo-oligosaccharide is synthesized by sialyltransferase Cst-II, N-acetylgalactosaminyl-transferase CgtA, and galactosyltransferase CgtB. There is a strong association between the simultaneous presence of these genes and Guillain-Barré syndrome-associated C. jejuni strains. Knockout mutants of C. jejuni genes involved in lipo-oligosaccharide sialylation had reduced reactivity with anti-GM1 sera from Guillain-Barré syndrome patients, and did not induce an anti-GD1a IgG antibody response in mice. Lipo-oligosaccharide biosynthesis genes appear to be essential for the induction of anti-GM1 or anti-GD1a IgG antibody and the subsequent development of acute motor axonal neuropathy.

SUMMARY

The concept that carbohydrate mimicry causes autoimmune disease provides a clue to the resolution of the pathogenesis of other immune-mediated diseases.

Exchange of lipooligosaccharide synthesis genes creates potential Guillain-Barre syndrome-inducible strains of Campylobacter jejuni

Human ganglioside-like structures, such as GM1, found on some Campylobacter jejuni strains have been linked to inducing the Guillain-Barré Syndrome (GBS). This study shows that a C. jejuni strain without GM1-like molecules acquired large DNA fragments, including lipooligosaccharide synthesis genes, from a strain expressing GM1-like molecules and consequently transformed into a number of potential GBS-inducible transformants, which exhibited a high degree of genetic and phenotypic diversity.

A Rare and Life Threatening Complication of Prosthetic Valve Endocarditis

Up to 70% of cases of Guillain-Barré syndrome (GBS) follow a preceding infection and a number of infectious agents have been described. We present a previously unreported association of Streptococcus viridans infective endocarditis affecting a prosthetic aortic valve and Guillain-Barré syndrome. This case highlights that this potentially life-threatening diagnosis should be considered in any patient presenting with symptoms of peripheral nervous system dysfunction following an infective illness.