gbs.org

A collection of resources and information about
Guillain-Barré, C.I.D.P., Miller Fisher and other related syndromes.

Development of Guillain-Barre Syndrome Following Campylobacter Infection

With the decrease in polio, GBS has become the leading cause of acute flaccid paralysis in the world.

GBS can probably result following a number of bacterial and viral infections. Campylobacter jejuni induced diarrheal disease is most often recognized as the precedent infection.

The epidemiology of Campylobacter associated with GBS is complex and not well understood. The specific reservoirs for GBS-related strains are not known. There appears to be seasonality of infection (summer) in some countries but no seasonality of GBS. The patterns of association seem to be different in different parts of the world, as does the age of individuals developing GBS.

There is an association of GBS with C. jejuni O serotypes 2,4,19, and 41. The strongest association has been with O19. For example, in the U.S., the risk of developing GBS following C. jejuni infection has been estimated as 1 in 1058, but as 1 in 158 following infection with C. jejuni O19.

The structure of LPS is complex and unique in Campylobacter. These unique structures are evident in O side chains and core oligosaccharides. Often, portions of these structures resemble mammalian tissue gangliosides (molecular mimicry) and suggest a mechanism of immune damage to nerve fibers.

The Department of Defense has developed, and is testing, a formalin-inactivated, whole cell, Campylobacter jejuni vaccine candidate. It is designated strain 81-176 and is a Lior type 5 (heat labile antigen based typing system) and O type 23/36.

A significant amount of antibiotic resistance has been developing among the Campylobacter. This could lead to an increasing problem in treatment of human disease.

The development of GBS is rare in children less than 2 years of age despite their susceptibility to Campylobacter. This may indicate that some maturation of the immune system is needed for GBS to manifest.

The medical costs associated with Campylobacter induced GBS has been estimated by the USDA to be between $57 and $425 million per year in the U.S. Total costs, which include days of lost productivity, are estimated to be between $247 million and $1.8 billion per year.

There is need for better standardized case definitions of acute motor axonal neuropathy (AMAN), acute motor-sensory neuropathy (AMSAN), acute inflammatory demyelinating polyneuropathy (AIDP), and Miller Fisher Syndrome (MFS) which are based on clinical, electrophysiologic, immunologic, and molecular data.

RECOMMENDATIONS

The CDC surveillance for emerging diarrheal diseases should include Campylobacter jejuni, and upsaliensis in their plans. This would provide a better estimate of Campylobacter infection rates in this country.

GBS (or more broadly defined acute flaccid paralysis cases) should be reportable by state health departments to the CDC. Current estimates are in the order of 1-4 cases of GBS per 100,000 population per year in the U.S. When combined with increased surveillance for Campylobacter, a much better picture of the epidemiology of the organism and its association with GBS should become apparent.

Surveillance for GBS in targeted populations seems warranted, particularly in China (efforts are underway) where an increase in GBS is seen in the summer months and is associated with rural residence, and in Latin America (not underway) where cases of acute flaccid paralysis has not declined despite the tremendous decrease in polio cases.

Studies should proceed on HLA typing of clinically well defined cases and controls in order to determine if there is a genetic component to host susceptibility to GBS.

Standardized microbiological laboratory procedures are needed to insure isolation of Campylobacter strains associated with GBS. In particular C. jejuni, and C. upsaliensis should be looked for. The concept of viable but non-culturable Campylobacter should be examined.

Serologic assays for diagnosis of C. jejuni infections need to be standardized and validated.

A diagnostic test specific for various Campylobacter species is needed. It is likely that a large number of Campylobacter infections go unrecognized.

An animal model for Campylobacter enteritis with ensuing GBS is urgently needed. A recently described ferret model for Campylobacter-induced enteritis may be useful. Mouse, rat, primate, chicken, and rabbit models for immune neuropathies are being examined and show promise but need to be developed further, perhaps by examining pathogen-free animals. The development of transgenic mice should also be considered.

There should be a Campylobacter strain bank established in which bacterial strains isolated from patients who develop Guillain Barre Syndrome (or variants) can be deposited. These strains should be available to researchers in the field. There is a role that NIAID could play in the storage and distribution of strains from the NIAID repository.

There is a need for standardized reagents, particularly monoclonal antibodies, that can be used to identify bacterial epitopes and which can be tested for their ability to react with different neural "targets". Well characterized reagents could also be distributed to researchers from an NIAID repository.

A more complete LPS typing system that will include more of the strains now classified as "un-typeable" is needed. Dr. John Penner, who developed the current system is ideally suited to perform this task. LPS typing should be complemented with a molecular typing system based on DNA restriction length polymorphisms (RFLP), rRNA gene polymorphisms (ribotyping), or by polymorphism of other (flagellar?) genes.

Continuing effort is warranted to determine the LPS structures associated with the development of GBS. Identification of specific epitopes would be helpful. Since sialylated polysaccharides are suspect, a probe to detect the presence of sialyl transferase may be helpful in identifying GBS-associated strains.

The mechanism of immune mediated nerve damage is poorly understood. The nature of the initial antigen-antibody reaction(s) which leads to damaging immune reactions which may involve cell mediated immunity, complement fixation, cytokine production, lymphocyte and macrophage infiltration, and breech of the blood-nerve barrier need to be better defined. Why gangliosides on nerves are particularly targeted or sensitive when compared to the same molecules found on other tissues is not known.

Studies should be done to try to understand the variations noted in seasonality, or lack thereof, of GBS, and of the basis for the differences noted in the serotypes of C. jejuni that have been associated with the onset of GBS in different studies and in different regions of the world.

The mechanism of intravenous immunoglobulin (IVIG) amelioration of GBS symptoms is not known. More research is needed with the aim of developing improved therapies.

A mechanism to share preliminary information among scientists studying Campylobacter and/or associated GBS would be helpful in keeping this world-wide research community in contact. The ability to send such information to an Internet address, for example, that would be widely accessible was discussed. Posting of interesting new observations, information, or questions would facilitate research efforts by all involved. Information on DNA sequences, availability of new strains or reagents, new techniques, reservoirs of infection, structures of LPS or proteins, new typing methods, antibiotic resistance patterns, frequency of isolation of particular serotypes associated with GBS, epidemiology, etc. could be included in such an exchange.

The "Development of Guillain-Barre Syn- drome Following Campylobacter Infection".
INTRODUCTION &
Normal opening comments & welcome to the confer- ence. Pointed out the importance of Campylobact- er in the GBS scene; its recognition as the prin- cipal cause of GBS as well as diarrhea around the world; the need for vaccines, etc.

CLINICAL AND EPIDEMIOLOGIC FEATURES IN GBS
Onset is usually rapid and disease has usually run its course in 4 - 8 weeks. With the chronic (CIDP) version, onset is much slower, sometimes months or years, and disease has usually run its initial course in 8 weeks.
Pointed out the differences between GBS, CIDP, Mil- ler-Fisher variant, etc. which we are mostly famili- ar with here.
Rate runs from 0.4 to 4.0 per 100,000 population. Is more common to men than women, and to the young and old in the population.
GBS infection from Campylobacter infection is more common in males than females, and demonstrates seasonality only in China, though there is some evidence of seasonality appearing in Africa.
A recent English study of 79 patients revealed that 16% had previously experienced diarrhea. A one-year follow-up of this group revealed 8% died, 4% were bed-bound, and 9% were still unable to walk without aid.

CAUSES OF GBS :
Rabies Vaccine
Swine Flu Vaccine
CMV (Cytomegalovirus) herpes EBY
CAMPYLOBACTER JENUNI (Light in AIDP, High in MFS cases).

DIFFERENCES BETWEEN AMAN AND AIDP
SUBTYPES :
AIDP - Diagnosis and analysis are usually very slow though condition deter- iorates very rapidly. Axon (motor nerves) are usually not affected and damage is to the peripherals.
AMAN - (Acute Motor Axonal Neuropathy) where the motor nerves are affect- ed, though sometimes only in the ventral roots near the spine.
AMSAN - (Acute Motor-Sensory Axonal Neuro- pathy) where there is degeneration of the motor & sensory fibers and spinal fiber deteriation as well. These cases have poor prognosis for good recovery.
CIDP - (Chronic Version) Generally more similar to AIDP, but recurs period- ically requiring frequent treatment.
Pointed out that while AIDP severely affects the sensory (peripheral) function; AMAN/AMSAN severely affect the motor function while peri- pherals remain almost normal.

PATHOLOGY OF GBS AUTOPSIES
34 of 57 autopsied cadavers presented with AIDP. 1 of 57 autopsied cadavers presented with MFS. Lymphocitic effects were noted in AIDP, not AMAN cases.
Noted that in AMAN cases, if only ventral roots were affected, recovery was easier & quicker.
Noted case studies where serum from human AMAN patients had been proven to infect chickens & rabbits.

THERAPY OF GBS THAT POINTS TO PARTICULAR PATHOGENETIC MECHANISMS
Pointed out that while plasma exchange & IVIG were effective in 80% of sensory/motor cases, plasma exchange appears much more effective in cases of diarrheal involvement. We note this effect later on in the case of South Africa where plasma exchange is the only treatment in a majority of cases with good results.

PANEL DISCUSSION
Pointed out chicken experiments demonstrated ability to in- duce paralysis by infusion of human strain.
Indications are the occurrences following diarrhea herald poor recovery prospects. (Suggest Campylobacter).
M-F variant has good recovery - complicated by other varieties, paralysis & death.
Colombia reported cases traced to sewer break contaminating a water system.
Mongolia traced 20 cases to a common water supply.
No recorded cases with parent/child GBS victims.
Little evidence of human/human transmission.
Evidence of seasonality developing in Africa, not confirmed.

CLINICAL AND EPIDEMIOLOGIC FEATURES OF C. JEJUNI INFECTION
Clinical & Epidemiological evidence features C. jejuni as the predominant cause of GBS. Campylobacter cases outnumber cases of Shigella & Salmonella combined. Many cases of C.j. are not reported. Are perhaps 4 million+ cases annually in the US. Summer is peak season. Half of all cases are from chicken (pri- marily undercooked).
There is evidence of immunity in foreign countries (bulk of victims are children). In US and the West, the bulk of victims are the elderly. See Navy experiments later on.

MICROBIOLOGY OF C. JEJUNI
8 - 30% isolation of C.J. from GBS patients. Bacteria re- quires temperature of 37 - 42 degrees C. for growth. Are many subtypes of Campylobacter other than the the jejuni. There is a need to study worldwide strains of Campylobacter.

LPS STRUCTURE AND CONSERVED CHARACTERISTICS OF C. JEJUNI
Lipopolysacharide is immuno agent allowing C. J. to begin GBS attack. C. J. similar in structure to Gangliocides, et al. This discussion became very technical and will be discussed in connection with DNA etc. further on.

C. JEJUNI SURFACE STRUCTURES OTHER THAN LPS (Dr. Guerry)
Other chief characteristic of C.J. is that it has a flagel- la (lashing tail) to help it move about in the intestinal tract.

PANEL DISCUSSION :
Campylobacter count drops over time in humans due to the immunity factor.
Immuno-depressed victims retain C. J. longer (HIV patients).
There is much variability among the Campylobacters. Must work toward an average since there is no standard.

ASSOCIATION OF C. JEJUNI INFECTION AND GBS
A large amount of statistical data were exhibited with this discussion. When the documented data are available in print- ed form, we will try to make the stats available.
Worldwide, 60 - 70% of GBS cases are preceded by C. J. infec- tion. 30 - 40% of GBS victims had C. J. infection. Penner type O-19 antibody disproportionately results in GBS.

EVIDENCE THAT O19 STRAINS ARE DISPROPORTIONATELY IMPORTANT
C.J. infection is seasonal - summer. 60% of GBS patients had a prior C. J. infection. In Japan, peak age 20; in China under age 5; in us over 60. In Japan 23% of GBS vic- time were infected with C. J. vs 1.2% for non-victims.

DIVERSITY OF LIPOPOLYSACCHARIDE STRUCTURES IN C. JEJUNI
Dr. Penner, father of antibody classifications or the US & Canada set out to disclose the wide variety of such structures (which are capable of starting the demyleating process involv- ed in GBS) present in Campylobacter jejuni. He approached this with DNA analysis and it was just too complex to follow in the time available, and as a layman. If you witnessed the O.J. Simpson trial, you are familiar with this.

GBS IN SOUTH AFRICA ASSOCIATED WITH C. JEJUNI 041
GBS in South Africa is associated with C. jejuni. He has been following GBS since 1975 - average 10 cases/year. They do not use IVIG - all cases are assumed from Campylo- bacter jejuni. Did report one case of a young man (21) who had poor recover level after 3 months & went home in bad shape. Perhaps IVIG would have helped in his recovery.
This session, too, was heavy on DNA and time available just does not allow copying data in sufficient detail to be meaningful.

PANEL DISCUSSION
Heavily involved with tabular data on antibodies & DNA.

DNA EVIDENCE INVOLVING LARGE VOLUMES OF STATISTICAL TABLES AND ANTIBODY MARKERS.

MECHANISMS for C. JEJUNI INFECTION CAN LEAD TO GBS :

IMMUNE MECHANISMS IN GBS
Immuno mechanisms are active in the arising of GBS.
T-cells are active in moving through the blood bar- rier. This has not been shown to be done by Gang- liocides. Antibodies are involved, and their action is different in AMAN vs ADIP. Macrophages are activ- ated by T-cells and antibodies and emit substances which result in demyleation (stripping) of the nerve cover (Myelin). Antibodies released by Schwan Cells & others then attack the nerves themselves.

MECHANISM OF ACTION OF GM1 & GQ1b ANTIBODIES :
Monoclonal antibodies and gangliocides are active (GM1, GM2, GD1b, CT1a & others). The antibodies attach to the nerve cells & fibers after Myelins has been stripped by Macrophages and wreak their damage.

CROSS-REACTIVITY OF C. JEJUNI, GM AND OTHER NATURAL ANTI- GENS :
There is cross-reactvity. Appears GM1a6 can cause pure motor-axonal damage. Evidence gangliocide can cause GBS. There were 31 strains isolated from isolates from GBS cases; 6 from MFS patients & 215 from Enteritis patients. Anti-GM from the rat has been shown to trigger human muscle response. Miller- Fisher Syndrome appears to be antibody GQ-1bAB.

ANTI-GM IN GBS :
Most patients have only a few antibodies. Depends on location of patients. Also, sensitiv- ity of testing and specifity of results. Is polyre- active - more disease specific.

BETA-TUBULIN AS A TARGET IN CHRONIC DEMYELINATING POLYNEURO- PATHIES :
Antibodies (BT) are involved in CIDP. IGM is reactive with BT and are demylenating in combination. Evidence of these appeared in 57% of CIDP cases, but incidence was low in China.

T-CELL REACTIVITY TO P2 PROTEIN :
P2 is reactive with T-Cells in cases of Enteritis & GBS. Lymph cells of the Lewis Rat were analyzed, then injected into 90 other rats which proved to develop same symptoms. Tissues were studied and was found that Interferon peaks in 16 days. Evidence is Anti- P2 is strongest in AIDP patients. Role of T-Cells in GBS appears to be to mimic antigens.

INSIGHTS FROM THE LEWIS RAT MODEL :
Observations of rats injected : Day 10 nerves were im- pacted. Days 11/12 - Lymphocytes were affected. Days 12/13 Macrophages reacted and demyleination began coup- led with conduction blocking. Migration of T-cells are blood/nerve in nature. Lymphocytic action stimulates Macrophages into substance production producing demylen- ation & nerve blocking. Used cobra venom to reduce in- flammation and demylenation in rats.

MECHANISMS FOR INJURY OF SCHWANN CELLS :
Schwann cells act as moderator. The rat body generates immunity over time. Molecules produced bypass the blood/ nerve barrier.

ROLE OF CYTOKINES IN SCHWANN CELL DAMAGE AND PROTECTION :
Cytokines are made by all cells not just inflammatory cells. Process of Schwann cell is to begin healing.

DIFFERENTIAL DISTRIBUTION OF HLA ALLELES IN TWO FORMS OF GBS :
This discussion was strictly DNA based. It was accomp- anied by large volumes of statistics and DNA charts and I got very little from it.

HUMAN TRIALS WITH C. JEJUNI VACCINES :
The Navy has pioneered the production of a vaccine a- gainst Campylobacter jejuni because of the impact of the disease on the personnel in its worldwide opera- tions. They noted evidence of early immunity in third world countries where most cases occur below age 5, and set out to produce the immune effect. Have experi- mented with both live strain & killed whole-cells which have proven much safer. CJ 81-176 strains have been studied. Tests showed 100% infection rates with 47% illness. retests showed 100% immunity. Vaccine is manufactured in the US.
Test vaccine was administered orally in animals (mice, rabbits, & ferrets), also in humans where it is admini- stered with bicarbonate as a buffer. Checks are made in humans at 28 & 60 days, and blood is cultured weekly for 60 days. Report minor effects from all dosages.
Tests are run on strains other than H21, which appears to be the culprit in GBS cases from Campylo. Also, screen out anyone with a history or family history of GBS.

FDA VACCINE CONSIDERATIONS :
Explained function of the FDA in vaccine evaluation. FDA finds such workshops to be very helpful. FDA examine all available evidence and if vaccine demon- clear effectiveness goes to 3 phases of testing: Small group (30 - 40) person testing; Larger group (100 - ?00) person testing watching efficacy & safety in larger doses; & finally major (?,000's) person testing watching for efficacy & safety in a controlled environment. Post- licensing FDA may call for additional data and follow-up.

HUMAN TRIALS WITH C. JEJUNI VACCINES :
Basically a rehash of the Navy data, but pointed out that the O19 antibody, the root cause of GBS is be- coming somewhat resistant to serums in CJ vaccine testing.

PANEL DISCUSSION :
Provided statistics on economic impact of Campylobacter jejuni-induced GBS. Annual cost of CJ-induced GBS is estimated at .6 - 1.0 billion dollars. All types of Campylo damage is valued at 5.6 - 9.4 billion dollars.

GENERAL DISCUSSION OF RESEARCH NEEDS AND OPPORTUNITIES :
Patient, tissue, specimen, skin banks are needed. Mandatory reporting of diseases such as Enteritis, GBS. Campylobacter infection, etc. are needed, but how to clarify what represents a reportable event, etc. Need better capability of assessing capability of treatments such as IVIG, steroids & plamapheresis in individual cases.
Need to increase the use of animal models in evaluating the above diseases. To standardize much of the data becoming available today in these cases. Need increased epidemiology in geographic areas at high risk for Campylo and to see what can be done to reduce the disease reser- voir - example in animals.
Need to determine how & why IVIG works so well in so many disease situations. My local doctor says he knows very well why it works - IVIG is pooled from a large number of donors who have had a wide scope of disease exposures - hence a strong dose of a wide variety of antibodies to various diseases.