A retrospective analysis of possible triggers of Guillain-Barre syndrome.

Antecedent infections have been found to be the most common trigger for Guillain-Barre syndrome (GBS). In the present study, we retrospectively analyzed 36 adult patients with GBS and found that surgery, trauma and treatment with ganglioside were also common before the onset of GBS. The proportion of the axonal subtype of GBS in post-surgical/traumatic patients was higher than that in non-surgical/traumatic patients (P=0.013) in the present study. In conclusion, this study has shown that prior infection, surgery, trauma and ganglioside may be clinical contributors to the onset of GBS and raised the possibility that they may act synergistically as triggers for the development of GBS.

More severe manifestations and poorer short-term prognosis of ganglioside-associated Guillain-Barré syndrome in Northeast China.

Ganglioside as a neurotrophic drug has been hitherto widely used in China, although Guillain-Barré syndrome (GBS) following intravenous ganglioside treatment was reported in Europe several decades ago. We identified 7 patients who developed GBS after intravenous use of gangliosides (ganglioside+ group) and compared their clinical data with those of 77 non-ganglioside-associated GBS patients (ganglioside- group) in 2013, aiming at gaining the distinct features of ganglioside-associated GBS. Although the mean age, protein levels in cerebrospinal fluid (CSF) and frequency of cranial nerve involvement were similar between the two groups, the Hughes Functional Grading Scale (HFGS) score and the Medical Research Council (MRC) sum score at nadir significantly differed (4.9 ± 0.4 vs 3.6 ± 1.0; 7.7 ± 5.5 vs 36.9 ± 14.5, both p<0.001), indicating a higher disease severity of ganglioside-associated GBS. A higher ratio of patients with ganglioside-associated GBS required mechanical ventilation (85.7% vs 15.6%, p<0.01). The short-term prognosis of ganglioside-associated GBS, as measured by the HFGS score and the MRC sum score at discharge, was poorer (4.3 ± 0.5 vs 2.8 ± 1.1; 17.3 ± 12.9 vs 46.0 ± 13.9, both p<0.001). All the patients in the ganglioside+ group presented an axonal form of GBS, namely acute motor axonal neuropathy (AMAN). When compared with the AMAN patients in the ganglioside- group, more severe functional deficits at nadir and poorer recovery after standard treatment were still prominent in ganglioside-associated GBS. Anti-GM1 and anti-GT1a antibodies were detectable in patients with AMAN while not in patients with the demyelinating subtype of GBS. The concentrations of these antibodies in patients with AMAN were insignificantly different between the ganglioside+ and ganglioside- groups. In sum, ganglioside-associated GBS may be a devastating side effect of intravenous use of gangliosides, which usually manifests a more severe clinical course and poorer outcome.

Bovine complex milk lipid containing gangliosides for prevention of rotavirus infection and diarrhoea in northern Indian infants.

Rotavirus (RV) is a leading cause of morbidity and mortality in children younger than 5 years of age, presenting commonly with diarrhoeal symptoms. In a prospective 12-week double-blind randomised controlled trial we assessed acceptability and efficacy of a high-ganglioside complex milk lipid (CML) for prevention of RV infection in 450 infants, ages 8 to 24 months, at 3 sites in northern India. Prevalence of diarrhoea and RV was unseasonably low at baseline (all-cause diarrhoea [ACD], n = 16; RV diarrhoea [RVD], n = 2; RV infection, RV positive [RV+], n = 20) and throughout the trial, with only 110 total episodes of ACD for 12 weeks (CML, n = 62; control, n = 48) of which 10 were RVD (CML, n = 4; control, n = 6). Mean duration that RVD persisted was lower in the CML group (2.3 ±â€Š0.5 days) than that in the control group (3.8 ±â€Š1.3 days, P = 0.03), but only 3 of 450 end of trial stool samples were identified as RV+ (<1%; CML, n = 2; control, n = 1). This hampered the assessment of efficacy of CML, despite the large a priori determined sample size. During the trial similar numbers of infants reported adverse events (AEs: CML 41%, control 46%), with the majority of events classified as mild and not related to the intervention. In conclusion, further clinical trials against a higher background of seasonal prevalence are necessary to assess efficacy of this nutritional intervention to prevent RVD. More important, however, high-ganglioside CML was acceptable for long-term consumption in infants ages 8 to 24 months.

Is there a decrease in Guillain-Barré syndrome incidence after bovine ganglioside withdrawal in Italy? A population-based study in the Local Health District of Ferrara, Italy.

There have been many reports of cases of Guillain-Barré syndrome (GBS) after therapeutic injection of bovine ganglioside preparations with the result that they were withdrawn in Italy in December 1993. As the relationship between bovine gangliosides and GBS has not yet been established, a further epidemiological investigation in the Local Health District (LHD) of Ferrara, Italy, was carried out in the years 1994-2001 to verify whether the incidence of GBS had changed after ganglioside withdrawal. The other aim of this investigation was to update the incidence of GBS in this area since the two previous investigations we carried out showed an increase in incidence from the years 1981-1987 to the years 1988-1993. The cases of GBS were identified prospectively. To guarantee completeness of case ascertainment, an intensive retrospective survey of all possible sources of cases for the entire study period was performed. The mean annual crude incidence rate in the years 1994-2001 (based on 26 new cases) was 1.97 per 100,000 population (95% CI 1.29-2.89), whereas it had been 1.87 per 100,000 population (95% CI 1.35-2.52) in the years 1981-1993 (based on 43 cases) when gangliosides were available. The age-adjusted rates were almost identical (1.66 and 1.65 per 100,000 population, respectively). Although ganglioside administration could have triggered, on the basis of an individual susceptibility, an immunologic reaction which produced GBS, the incidence of GBS in the study area did not change after ganglioside withdrawal. In the whole period 1981-2001, a temporal pattern of incidence was reported with an increase towards a peak in 1990-1992 and a progressive decline thereafter. This temporal pattern did not seem related to ganglioside withdrawal, and no definite explanation for it was found which could imply that the disease incidence is less stable than it was deemed.

Paraneoplastic ophthalmoplegia and subacute motor axonal neuropathy associated with anti-GQ1b antibodies in a patient with malignant melanoma.

A 68 year old woman developed oculomotor paresis shortly after metastatic progression of her melanoma was discovered. She was then immunised with the tumour antigen MAGE-3 in combination with an immunological adjuvant. During immunisation her symptoms worsened and she developed severe, predominantly proximal axonal motor neuropathy and became bedridden. IgM antibodies against gangliosides GM2, GD3, and GQ1b were detected in serum obtained two weeks before and nine weeks after the onset of symptoms. Immunohistochemically, the patient's IgM reacted with the tumour and co-localised with GQ1b. She improved neurologically following steroid treatment and became ambulatory.

Tolerability and safety of two new preservative-free tear film substitutes.

PURPOSE: The tolerability, safety, and visual comfort of two new tear film substitutes were studied in a phase I clinical study. METHODS: Two amphipathic lipids (phosphatidylcholine, cholesterol, sphingomyelin, and gangliosides) containing solutions (I and II) of well-defined stoichiometry, free of preservatives, were studied in 20 eyes of 20 healthy volunteers (age range, 26-32 years) in a randomized, double-blind, crossover study. Randomization was achieved by treating one eye of each volunteer four times daily for 7 days with composite solution I. The contralateral eye served as a control. After a washout interval of 7 days, the same eye was treated similarly four times daily with the solution II under randomizing conditions. Slit-lamp biomicroscopy, visual acuity, visual analog scales, and side effects were monitored at the beginning of the study weekly and for 3 weeks. RESULTS: The tear substitutes proved to have no influence on the visual acuity and were safe and well tolerated. No allergic reactions or any other side effects such as hyperemia, corneal disturbance, and foreign body deposits were observed in any volunteer. CONCLUSION: The biophysical properties of the amphipathic lipids comprising the two preservative-free tear film substitutes were studied in monolayer experiments. They form reversibly compressible and expandable monomolecular films at the air-water interface, a prerequisite for the mimicry of the tear film produced normally by meibomian glands. The efficacy and safety of both medications will be investigated in patients with keratoconjunctivitis sicca and dry eye syndrome in future experiments.

Gangliosideos e a resposta de hipersensibilidade retardada em camundongos / Gangliosides and the delayed hypersensitivity response in mice

Em trabalhos anteriores mostrou-se que os gangliosídeos (GSLs) têm um efeito inibitório sobre a proliferação linfocitária e a síntese de IL-2, assim como sobre a reação mista de linfócitos. Neste estudo objetivou-se avaliar o efeito dos GSLs sobre a resposta de hipersensibilidade retardada. Foram utilizados 12 camundongos BALB/c, machos, pesando em média 30 gramas, provenientes do biotério setorial da Disciplina de Parasitologia e mantidos por 5 dias para adaptação no biotério setorial da Disciplina de Técnica Operatória e Cirurgia Experimental da UNIFESP-EPM, recebendo água e ração própria para a espécie. Os animais foram distribuídos em três grupos, de acordo com as doses de GSLs, da seguinte forma: grupo 3mg. kg-1, grupo 9mg. kg-1 e grupo simulado (veículo). Os animais foram tratados, por via intramuscular, nos dias 0 e 4. O parâmetro avaliado foi o edema da pata traseira esquerda no local da inoculação do antígeno. Os animais foram anestesiados com Cetamina (60mg.kg-1) e Xilazina (10mg.kg-1), por via intramuscular, sendo em seguida submetidos à dissecção da veia jugular direita, por onde foram inoculadas 10(6) hemácias de Carneiro no dia 0, para sensibilização. No dia 4 subsequente, os animais foram novamente anestesiados e receberam, por via subcutânea, 10(8) hemácias de Carneiro, num volume de 0,02ml. Foram realizadas medidas do edema da pata traseira com paquímetro 24, 48, 72 e 96 horas após o desafio. Os dados mostraram que após 48h houve um aumento do edema em animais dos grupos simulado e 3mg (médias=2,3 and 2,1mm, respectivamente), e os camundongos do grupo 9mg não apresentaram aumento importante (média=0,1mm). Entretanto, após 72h, o grupo 9mg apresentou aumento de 1,7mm enquanto, os outros grupos não apresentaram mudança significativa no edema da pata (médias=0,2 e 0,8mm), grupos simulado e 3mg, respectivamente) comparados aos dados do dia antecedente. Após 96h, todos os grupos apresentaram desaparecimento do edema. Com base nos dados obtidos pode-se concluir que a resposta de hipersensibilidade retardada alterou-se na vigência de alta dose de GSLs.

Long-term treatment of chronic chagasic cardioneuropathy with a mixture of gangliosides: effect on evolution of circulating antiGM1 antibodies.

Chagas disease involves a cardiac impairment, being the first alterations of autonomic disorders which affect heart rate and blood pressure control. At this stage, diminished heart rate responses to atropine and propranolol are observed. Prior studies have shown that short term ganglioside treatment improves the responses to these agents, but there is no information about the long term effect of gangliosides and the evolution of antiGM1 titers. The effects of long term treatment with gangliosides on autonomic tests in patients with chagasic cardiodisautonomy and the evolution of antiGM1 titers were studied in 90 patients (57 men, 33 women, aged 25-60 years) with positive serology for Chagas disease and electrocardiogram showing sinusal bradycardia and incomplete right branch block, without cardiomegaly, with autonomic alterations by postural and Valsalva's tests. All patients were submitted to a test that consisted of intravenous injection of atropine 0.04 mg/kg followed 3 min later by intravenous injection of propranolol 0.2 mg/kg. During these tests heart rate and blood pressure were recorded continuously. Subsequently, 30 patients were treated with 100 mg/day of a mixture of gangliosides by intramuscular injection during 15 days in a row, followed by 40 mg/day during another 75 days. Another 30 patients received continuous treatment for 12 months. The remaining 30 patients were controls. The antiGM1 antibody circulating titers were determined before the treatment, at the third and 12th month. Seventy-four patients completed the study. Before treatment, the heart rate increased, though slightly, after the injection of atropine. After 3 months of ganglioside treatment a statistically significant increase in the response to atropine was recorded. In the controls at 12 months, the response to atropine remained increased without differences between the patients treated for 3 and 12 months. The control patients did not show any modification of the heart rate response during 12 months. Both ganglioside-treated groups showed an increase in the response to propranolol. The antiGM1 titer distribution was similar in both healthy subjects and chagasic patients. None of the patients had positive antiGM1 titers in basal conditions nor significant modifications after the ganglioside treatment. Chagasic cardioneuropathy was not associated in this study with high antiGM1 antibody titers. Chagasic patients showed a diminished heart rate response to atropine as well as to propranolol. Ganglioside treatment determined an increased heart rate response, particularly after atropine. Increased heart rate response was maintained until 1 year, without differences between the patients treated for 3 and 12 months. No changes in the antiGM1 titers were observed during the ganglioside treatment.

Exogenous gangliosides and Guillain-Barré syndrome. An observational study in the local health district of Ferrara, Italy.

A retrospective study was carried out in the Ferrara Local Health District, Italy, for the period 1981-1993 (average resident population: 177,235 inhabitants) to establish whether people exposed to exogenous gangliosides had a higher risk of Guillain-Barré syndrome. The incidence of Guillain-Barré syndrome of 1.9/100,000 population/year [95% confidence interval (CI): 1.3-2.5] reported in Ferrara Local Health District in the same period was used as a reference for comparison. The data bank of Ferrara Local Health District made it possible, first to estimate the number of individuals exposed to gangliosides in the resident population of Ferrara Local Health District (3.7%), the number of ganglioside prescriptions and the number of cases of Guillain-Barré syndrome who had treatment with gangliosides (nine patients, 20.9%), and, secondly, to verify the sequence of events between the ganglioside injection and the onset of the disease. Seven of the nine patients (77.8%) received gangliosides as treatment for peripheral neuropathy (Guillain-Barré syndrome onset before gangliosides were prescribed). For the other two patients (22.2%) a possible appropriate temporal sequence between ganglioside injection and onset of Guillain-Barré syndrome was found. Based on two possible ganglioside-related cases, the risk of Guillain-Barré syndrome was higher in the exposed (0.53/100,000 population/month following ganglioside injection; 95% CI: 0.06-1.91) compared with the unexposed population, but the difference was not significant. When only individuals prescribed with mixed gangliosides were considered (both possible ganglioside-related Guillain-Barré syndrome cases received mixed gangliosides), the risk of Guillain-Barré syndrome was higher (0.64/100,000 population/month following ganglioside injection; 95% CI: 0.08-2.31) but the difference from the risk in unexposed individuals was not statistically significant. The relative risk for the exposure to mixed gangliosides was borderline (relative risk = 4.3; 95% CI: 1.0-17.8). The wide 95% confidence intervals were a consequence of sample size limitations. Considering also that the exposed and unexposed groups differed in age (those exposed were older than those unexposed and the age-specific incidence of Guillain-Barré syndrome in the study population increased with increasing age), the present findings question either a strong increased risk of Guillain-Barré syndrome in people exposed to exogenous gangliosides or an immunogenic role of these agents in humans. However, because of the limited sample size, the results are not conclusive.

Gangliosides and Guillain-Barré syndrome.

Cases of Guillain-Barré syndrome (GBS) associated with parenteral use of gangliosides have been reported in several European countries. To evaluate the hypothesis of association between ganglioside exposure and occurrence of GBS, a case-control study was conducted. GBS cases discharged during 1989 from public and private hospitals in three Italian provinces were identified: 42 GBS cases and 420 controls matched on age and gender were enrolled. Data of onset of symptoms of GBS was taken from clinical records. Exposure status of subjects was ascertained through the regional computerized drug prescription monitoring system. The odds ratio of association between ganglioside use, in the 30 days prior to onset of symptoms, and GBS was 9.1 (95% confidence interval 2.8-29.4). Although there are formidable difficulties in distinguishing prodromal therapy of GBS from drug causation, the association with ganglioside therapy is strong and supportive of the hypothesis of a role of ganglioside preparations in the occurrence of GBS.

Acute axonal Guillain-Barré syndrome with IgG antibodies against motor axons following parenteral gangliosides.

We studied 7 patients with an acute motor axonal Guillain-Barré syndrome (GBS), manifested 5 to 15 days after parenteral injection of a commercial ganglioside preparation given for nonspecific pain syndromes. The serum IgG and IgM antibody response to ganglioside was studied serially and the recognition of epitopes on the peripheral nerves and motor end-plates was examined using biotinylated IgG extracted from the patient's serum. Sera from 8 patients treated with the same ganglioside preparation who did not develop neuropathy and from 25 patients with classic GBS never treated with gangliosides were studied concurrently. All patients with ganglioside-related GBS had a rather severe axonal degeneration, incomplete recovery, and high IgG, but not IgM, antiganglioside antibody titers, ranging from 1:320 to 1:10,240. Seven (28%) of the 25 GBS patients had IgG antibody titers, ranging from 1:160 to 1:10,240. None of the ganglioside-treated patients who did not develop GBS and none of the 50 disease control subjects had IgG GM1 antibodies. Purified IgG from the patients with high GM1, antibodies, but not from the others, recognized epitopes at the nodes of Ranvier and the distal motor nerve terminals at the end-plate. We conclude that exogenous ganglioside injections can be immunogenic, triggering IgG antiganglioside antibodies with specificity for motor nerve-terminals. In some patients with axonal GBS such antibodies may be markers or mediators of axonal involvement.

Human tumor gangliosides inhibit murine immune responses in vivo.

Gangliosides which are shed by tumor cells clearly inhibit cellular immune responses in vitro. However, the immunosuppressive activity of these molecules have been more difficult to ascertain in vivo. Here we have adapted a murine model to determine the effects of tumor gangliosides in an in vivo microenvironment, the lymph node draining the site of stimulation by allogeneic cells. In this model, allogeneic splenocytes (BALB/c) are s.c. injected into C3H mice. The cellular immune response in the draining popliteal lymph nodes 4 days later is evidenced as an increase in lymph node mass (2-fold), lymphocyte number (6-fold), and lymphocyte DNA synthesis (6-fold). Purified human neuroblastoma gangliosides (10 nmol) coinjected with the stimulating allogeneic cells significantly suppressed this in vivo immune response. The increase in the lymph node mass was reduced by 65% (0.66 versus 1.89 mg), the increase in lymphocyte number (4.0 x 10(6) cells/node) was almost completely inhibited (1.1 x 10(6) cells/node), and in vitro [3H]thymidine uptake by the lymphocytes recovered in vivo was reduced by 80%. In contrast to the inhibition by tumor gangliosides, liposomes of cholesterol:lecithin were not inhibitory. Thus, tumor gangliosides, specifically, modulate cellular immune responses in vivo, which may contribute to the observed enhancement of tumor formation by these molecules.

Gangliosides. Their role in clinical neurology.

Gangliosides are normal constituent of mammalian vertebrate cell membranes and are particularly abundant in the central and peripheral nervous systems. The biological effects of exogenously administered gangliosides have been extensively investigated in vitro and in experimental animal models where they have neuronotrophic and neuritogenic properties. Despite these findings there is still little evidence that treatment with parenteral gangliosides in humans can be effective in peripheral neuropathies or other neuromuscular diseases. The initial preliminary reports on the positive effects of GM1 in cerebrovascular diseases and spinal cord injury need to be confirmed in larger controlled trials. At the same time the occasional development of an acute motor neuropathy clinically presenting as the Guillain-Barré syndrome and associated with high titres of anti-ganglioside antibodies highlights the risks of their widespread use before more consistent data on their efficacy become available.