The spectrum of antecedent infections in Guillain-Barré syndrome: a case-control study.

OBJECTIVE: To determine which antecedent infections are specifically associated with the Guillain-Barré syndrome (GBS). BACKGROUND: Infections with many agents have been reported preceding GBS. Some infections are related to specific clinical and immunologic subgroups in GBS. Most agents were reported in case reports and uncontrolled small series of GBS patients only, and their relation to GBS and its subgroups remains unclear. METHOD: A serologic study for 16 infectious agents in 154 GBS patients and 154 sex- and age-matched controls with other neurologic diseases. Acute phase, pretreatment samples were used from clinically well-defined GBS patients. The seasonal distribution of serum sampling in the GBS and control group was the same. RESULTS: Multivariate analysis showed that in GBS patients, infections with Campylobacter jejuni (32%), cytomegalovirus (13%), and Epstein-Barr virus (10%) were significantly more frequent than in controls. Mycoplasma pneumoniae infections occurred more often in GBS patients (5%) than in controls in univariate analysis. Infections with Haemophilus influenzae (1%), parainfluenza 1 virus (1%), influenza A virus (1%), influenza B virus (1%), adenovirus (1%), herpes simplex virus (1%), and varicella zoster virus (1%) were also demonstrated in GBS patients, but not more frequently than in controls. C. jejuni infections were associated with antibodies to the gangliosides GM1 and GD1b and with a severe pure motor form of GBS. Cytomegalovirus infections were associated with antibodies to the ganglioside GM2 and with severe motor sensory deficits. Other infections were not related to specific antiganglioside antibodies and neurologic patterns. CONCLUSIONS: Recent infections with C. jejuni, cytomegalovirus, Epstein-Barr virus, and M. pneumoniae are specifically related to GBS. The variety of infections may contribute to the clinical and immunologic heterogeneity of GBS.

[A case of neuroborreliosis with unilateral radiculoneuropathy and elevated serum antibodies for Borrelia garinii and Borrelia afzelii].

A 24-year-old male patient was admitted to our hospital because of dysesthesia and weakness of the right leg. Six weeks before admission he traveled to southern China. A week later he noticed multiple papules with itching on his right leg that were suspected to be insect bites. Four days later numbness of the right leg developed. Then he began to limp because of the leg weakness. Two weeks before admission severe pain in the right leg developed. On admission neurological examination revealed hypesthesia, muscle weakness and atrophy, areflexia, radicular pain and Lasègue sign of the right leg, and patchy hypesthesia of the left leg. The cranial nerves were intact, and meningeal signs were negative. Complete blood counts and serum biochemistry were unremarkable except for eosinophilia and mild elevation of IgE. A test for antinuclear antibody was positive. Cerebrospinal fluid was normal. Nerve conduction study and sural nerve biopsy showed multifocal severe axonopathy. Although antibody for Borrelia burgdorferi sensu stricto was negative, antibodies for B. garinii and for B. afzelii were positive in serum immunoblotting. Neurological symptoms improved after administration of intravenous ceftriaxon following oral doxycycline. In Japan, this is the second case of neuroborreliosis not due to B. burgdorferi sensu stricto. To test antibodies for B.garinii and for B. afzelii is recommended in patients with suspected neuroborreliosis.

Brucellosis and polyneuroradiculomyeloencephalitis. A case report.

Reports on simultaneous central and peripheral nervous system involvement in a patient with brucellosis are very rare. We report of one young female patient with a long history of consumption of non-pasteurized dairy products in which clinical and laboratory findings confirmed the existence of an active brucellosis with nervous system impairment. Cerebrospinal fluid (CSF) analyses were negative. Electrophysiology and positive findings on sural nerve biopsy complemented the diagnosis of polyneuroradiculomyeloencephalitis. Treatment with a combination of doxycycline and rifampin for 2 months was successfully applied. No relapse or sequelae occurred in the patient after 12 months of follow up.

Is it infectious?

The Autumn meeting of the English Branch of The British Society for the Study of Infection was held at the Zoological Society of London. Speakers from a breadth of specialties re-examined the clinical features and pathology of some remarkably diverse illnesses and addressed the question 'Is it Infectious?'

Acute lumbosacral polyradiculopathy in acquired immunodeficiency syndrome: experience in 23 patients.

We reviewed our experience in 23 patients with acquired immunodeficiency syndrome (AIDS) who had acute lumbosacral polyradiculopathy. The patients developed a distinctive syndrome of rapidly progressive flaccid paraparesis and areflexia that was frequently associated with sphincter disturbances. Persuasive laboratory evidence of a cytomegalovirus polyradiculopathy (polymorphonuclear pleocytosis or confirmatory cerebrospinal fluid culture) was found in 15 of the 23 patients. Treatment with ganciclovir in these patients led to clinical stabilization, although worsening during the first 2 weeks of treatment was common. Most patients with cytomegalovirus polyradiculopathy had severe residual deficits. Metastasis from systemic lymphoma accounted for the polyradiculopathy in 2 other patients. A more benign syndrome was identified in the remaining 6 patients. They generally had slower clinical progression and less severe neurological deficits at their nadir than did patients with cytomegalovirus polyradiculopathy. Unlike patients with cytomegalovirus infection, their cerebrospinal fluid showed a predominantly mononuclear pleocytosis. Moreover, spontaneous improvement without treatment was common. Our experience together with the published experience of others suggests that the acute lumbosacral polyradiculopathy in AIDS is a clinical syndrome with different etiologies and variable clinical outcome. Recognition of this heterogeneity is necessary for the management of individual patients, as well as the interpretation of treatment results.

Increased reactivity to HTLV-I in inflammatory nervous system diseases.

The presence of IgG antibodies reacting with purified and disrupted human T-lymphotropic virus type I (HTLV-I) was examined by an indirect enzyme-linked immunosorbent assay (ELISA) in sera from 49 patients with multiple sclerosis (MS), 21 patients with aseptic meningoencephalitis (AM), 12 patients with Guillain-Barré syndrome (GB), and 30 patients with tension headache (TH). This was also assessed in the concentrated cerebrospinal fluid (CSF) of most of these patients, as well as in sera of 60 blood donors (BD). Standardized amounts of serum IgG and CSF IgG were used in ELISA. For sera, higher reactivity with HTLV-I was found in all four patient groups compared with the BD group, but no significant differences were observed among the four groups. There was higher reactivity with HTLV-I in the CSF of patients with MS, AM, and GB compared to findings in patients with TH. Ten serum (2 MS, 3 GB, 3 TH, 2 BD) and 3 CSF (1 MS, 1 GB, 1 TH) specimens considered positive by ELISA for HTLV-I were found negative on confirmatory Western blot analysis. We extended this study to analyze the in vitro production of anti-HTLV-I-IgG antibodies by the 24-hour cultivation of unstimulated lymphocytes from peripheral blood and CSF of 6 additional patients with MS directly in HTLV-I antigen-coated wells of microtiter plates. This was followed by determination of specific antibodies by ELISA in the same wells. No antibody production was measurable. Our data do not favor the hypothesis of an HTLV-I-related human retrovirus in the etiology of MS.

[Clinical course of cytomegalovirus infection in adults]. / Klinik der Zytomegalie-Infektion des Erwachsenen.

Between 1972 and 1984 73 patients with acute cytomegalovirus infection have been monitored. In 55 patients case history did not reveal any former disease. In 18 patients the cytomegalovirus infection was a sequela of cardiac surgery ("postperfusion syndrome"), transplantation or underlying malignant disease. After a prodromal stage which comprised unspecific symptoms in most cases various organ manifestations were noted in the course of disease. Typical cases presented hepatitis, myocarditis, Guillain-Barré syndrome with or without thrombocytopenia and (or) lympho-monocytosis. The organ symptoms were varying in degree and resolved completely within 4 to 12 weeks. Only one female patient died from congestive heart failure due to myocarditis after one year.

Polyradiculoneuritis in children groups during simultaneous circulation of enteroviruses and adenoviruses.

Two cases of polyradiculoneuritis in children were noted during January, 1984. Each girl was a member of a different group of children: the first group was newly constituted of children from various remote regions of Czechoslovakia in a Medical Institution, the second one included children attending the same nursery school for a long time. In both groups, all or most of the children went through one or two respiratory infections which preceded the development of a paralytic disease. From the first girl, coxsackievirus A9 was recovered in nasopharyngeal swabs and in a stool sample. Among contacts in the Children's Medical Institution, a concurrent circulation of this enterovirus and of an adenovirus type 3 was demonstrated by isolation attempts and confirmed by serological examinations. From the second girl, coxsackie A9 and an adenovirus type 29 were demonstrated in the same stool sample and a simultaneous circulation of both virus species among the nursery school and family contacts was proved by isolation attempts and by serological investigations. The concurrent, overlapping or sequential circulation of adenoviruses and enteroviruses may perhaps contribute to a compromised immunity resulting in a manifestation of paralysis.

Cytomegalovirus infection in the normal host.

CMV mononucleosis often resembles EBV infectious mononucleosis; however, certain features of the history and physical may help to distinguish CMV from EBV. While CMV mononucleosis is usually self-limited, certain laboratory abnormalities may persist for months or years after the patient has recovered. Previous reports on CMV in the non-immunocompromised host have rarely described systemic complications. We have reviewed 10 cases of CMV with systemic manifestations at one institution over a 15-year period. These patients had prolonged fevers (often greater than three weeks) and the diagnosis was often unsuspected during the early part of the illness. While two patients required mechanical ventilation, all patients had self-limiting disease and survived. When CMV is suspected and diagnosed early in the course, numerous diagnostic (and potentially dangerous) tests can be avoided in a viral illness in which prolonged fever is common.

A theory of virus-induced demyelination in the Landry-Guillain-Barré syndrome.

The Landry-Guillain-Barré syndrome (LGBS) is a demyelinating disorder of the peripheral nervous system frequently preceded by infection with common viruses. Most prevalent among these agents are herpesviruses, particularly Epstein-Barr virus (EBV) and cytomegalovirus (CMV). The specific role played by antecedent viral infection in the pathogenesis of the LGBS remains obscure. In this regard, recent studies of Marek's disease (MD) neuropathy, an avian herpesvirus-induced experimental model for the LGBS, may provide insight. The autoimmune pattern of demyelination seen in MD neuropathy is histopathologically indistinguishable from that seen in the LGBS. In this paper, a comprehensive theory is discussed regarding the pathogenetic mechanisms that may be operative in the LGBS.

Guillain-Barré syndrome associated with Epstein-Barr virus in a cytomegalovirus-negative patient.

Epstein-Barr virus and cytomegalovirus have both been associated with Guillain-Barré syndrome after antibody investigations in several patients. In the teenage female patient in this present report, Guillain-Barré syndrome following infectious mononucleosis was associated with sero-conversion against Epstein-Barr virus but not cytomegalovirus. The findings are consistent with the hypothesis that Epstein-Barr virus might be an etiological agent for the Guillain-Barré syndrome and that infection with cytomegalovirus is not a requisite for the syndrome.