Treatment of immune deficient neuropathies with intravenous polyvalent immunoglobulins. An open study of 16 cases

Between June 1989 and February 1992, in an open controlled study 16 patients with various types of polyneuropathy were treated with high-dose intravenous immunoglobulins (IgIV). Every month during 3 months, each patient received three courses of IgIV in doses of 0.4 g/kg/day during 5 successive days. The trial was discontinued in case of no response or if the neuropathy was considered as being in remission. In the other cases, at most one course of IgIV was given once a month if there was significant improvement (assessed by previously published clinical functional scales, electrophysiological examinations and titers of specific antibodies), or spaced at intervals which varied according to each patient, and sometimes in low doses. Results: 1) A first group of 6 patients had chronic demyelinating polyneuropathy with severe motor disability. The first infusions of IgIV resulted, in 4/6 cases, in a dramatic improvement which lasted under regularly spaced courses in lower doses. 2) Four patients had chronic neuropathy associated with monoclonal IgM gammopathy of undetermined significance (3 had anti-MAG and anti-SPG antibodies, and 1 had anti-GD1a and GD1b antibodies) and had not been improved by the usual immunosuppressive treatments. In 1 case the IgIV treatment had to be discontinued because of skin allergy. In the remaining 3 patients the clinical disorders (mainly the sensory ones) were reduced, but no significant improvement of neurophysiological or immunological data was observed. 3) Three patients had a purely multifocal motor neuropathy with persistent conduction blocks at EMG and high titers of anti-GM1 antibodies in 2/3 cases.(ABSTRACT TRUNCATED AT 250 WORDS)     

Intrathecal synthesis of immunoglobulins in eosinophilic meningoencephalitis due to Angiostrongylus cantonensis

Eosinophilic meningoencephalitis due to the nematode Angiostrongylus cantonensis, which is endemic to Cuba, occurs in children and is due to accidental contact with soil snails. The course is less often fatal than in adult patients in southeastern Asia. Cerebrospinal fluid (CSF) and serum samples from 24 pediatric patients were analyzed and evaluated in CSF/serum quotient diagrams (Reiber graphs) to characterize the neuroimmunological response and the blood-CSF barrier dysfunction that occur in the course of the disease. At the time of the first diagnostic lumbar puncture, together with eosinophilic pleocytosis (1,920 +/- 400 cells/microl), intermediate blood-CSF barrier dysfunction (i.e., an increased CSF/serum albumin quotient) with no intrathecal immunoglobulin G (IgG), IgA, and IgM class response was observed in all cases. Seven days later, at the time of early clinical recovery, the blood-CSF barrier dysfunction was normalized in 75% of the patients, but meanwhile, intrathecal immunoglobulin synthesis emerged in all cases, as either a two-class response (IgG and IgA in 85% of the patients) or a three-class response (IgG, IgA, and IgM; 30%). The fraction of eosinophilic cells (40%) remained large despite a decreasing total cell count. The neuroimmunological pattern of this inflammatory response to the parasite and its toxins is discussed with regard to the CSF patterns of other infectious diseases caused by bacteria or viruses.     

Peripheral neuropathies in diabetes

Peripheral neuropathy in diabetes remains a difficult management dilemma. The clinical manifestations may vary widely. Polyneuropathies develop with increasing duration of disease, and a thorough understanding of the clinical manifestations, including sensory, motor, and autonomic deficiencies, helps guide diagnosis and treatment. A multidisciplinary approach emphasizing preventive care and timely intervention can decrease morbidity significantly and improve the quality of life for the patient. Properly fitting shoes and avoidance of foot trauma are cornerstones of preventive management. Strict control of serum glucose can alter the course of peripheral neuropathies. This control can be accomplished with a strict insulin regimen or pancreatic transplant. Further research is needed to increase knowledge about peripheral neuropathies in diabetes and aid the physician with new treatment options.     

Entrapment neuropathies

Relative frequency of entrapment neuropathies was studied from amongst the patients referred to an electrodiagnostic medicine laboratory for electrophysiological studies. During the study period electrophysiological procedures were done on 650 patients with various peripheral nerve disorders. The entrapment neuropathies constituted 8.5%. Carpal tunnel syndrome (CTS) was the commonest entrapment neuropathy (83.6%). Diagnosis of CTS was established in 84 Patients referred with the diagnosis of CTS. Electrophysiological tests confirmed the diagnosis of thoracic outlet syndrome in 4 (15.4%) of the 26 patients referred with this diagnosis and in 5 (19.3%) of them the diagnosis turned out to be CTS. Diagnosis of cubital tunnel syndrome was not suspected clinically in all the 3 patients, they were referred with the diagnosis of ulnar neuropathy. In both the patients with tarsal tunnel syndrome the initial diagnosis was peripheral neuropathy.     

Paraproteinaemic neuropathies

Paraproteinaemia and neuropathy are each relatively frequent and may be associated by chance. However, a number of significant relationships have to be ruled out in the differential diagnosis. Malignant gammopathy should be excluded: multiple myeloma can lead to compression of the spinal cord or cauda equina; primary amyloidosis is occasionally involved; the rare but intriguing POEMS syndrome, consisting of polyneuropathy, organomegaly, endocrinopathy, M-protein and skin changes, usually accompanies osteosclerotic myeloma. It can be associated with angio-follicular lymph node hyperplasia and needs to be recognized because radioablative therapy is curative. The 'benign' monoclonal gammopathies of undetermined significance, known as MGUS, are much more frequent. There is an IgM MGUS group with predominantly distal sensorimotor demyelinating polyneuropathy and another rather heterogeneous group with IgG or IgA MGUS and a tendency to a favourable response to plasmapheresis. The role of the monoclonal IgG and IgA antibodies is unclear. This chapter has focused on the pathogenetic mechanisms of neuropathies associated with IgM MGUS. In the majority of cases, monoclonal autoantibodies specific for particular carbohydrate epitopes bind to myelin and are now recognized as the primary cause of the disease manifestations, including widening of the myelin lamellae. While the autoantibodies have been shown to bind complement, the presence of inhibitors is invoked to explain the absence of acute inflammatory changes. The epitopes recognized with the highest affinity by the auto-antibodies are present on the myelin-associated glycoprotein (MAG) and could interfere with cell adhesion and cellular signally processes. In addition, binding to antigenically similar glycoproteins, such as PO, PMP-22 and some acidic glycolipids, may be a contributory factor. It is generally accepted that the anti-MAG autoantibodies are inducing a progressive demyelinating polyneuropathy by modifying axon-Schwann cell interactions.     

Painful neuropathies

Mercury can induce systemic autoimmunity in susceptible mouse strains characterized by a T-cell-dependent polyclonal B-cell activation, increased serum levels of IgG1 and IgE antibodies, production of autoantibodies, and the formation of immune complexes in the kidneys. However, certain resistant mouse strains do not show any of the autoimmune manifestations after mercury injection. Th1/Th2 dichotomy has been proposed to be responsible for resistance and susceptibility, respectively. Immunosuppression has also been suggested in resistant animals after mercury injection. To test whether immunosuppression or a biased Th1-type response was induced by mercury in resistant DBA/2 mice, we injected DBA/2 mice with mercury for 1 or 3 weeks and then immunized the mice with horse red blood cells (HRBCs) to study whether the subsequent humoral response to HRBCs was inhibited or skewed to the production of antibodies of IgG2a isotype switched by Th1-type cytokines. We found that there was no reduction of the number of splenic antibody-producing cells in the subsequent response to HRBCs compared with saline-treated mice. By haemagglutination tests, the titers of HRBC-specific antibodies were the same after HRBCs injection in both mercury- and saline-treated DBA/2 mice. There was no increase in total serum IgG2a antibody. Sera of both mercury- and saline-treated mice immunized with HRBCs showed high titres of specific IgM, IgG1 and IgG2a anti-HRBCs antibodies. Surprisingly, 3-week treatment with mercury induced a reduction in the titres of specific IgG2a anti-HRBCs antibodies in DBA/2 mice after immunization with HRBCs. Our results demonstrated that mercury did not induce a general immunosuppression or a biased Th 1-type immune response in resistant DBA/2 mice. The nonresponsiveness in mice resistant to mercury-induced autoimmunity must be due to some other unknown mechanism(s).     

Metabolic neuropathies

A large epidemiological study has documented that one-third of diabetic patients have peripheral neuropathy. Diabetes duration, poor glycaemic control, smoking and hypertension are all independent predictors of the incidence of diabetic polyneuropathy. High prevalence of autonomic dysfunctions, both sympathetic and parasympathetic, has been found in patients with nonalcoholic chronic liver disease. The pathogenesis of metabolic neuropathy is unclear; even immunologic factors might play a role in the development of diabetic autonomic neuropathy. No specific treatments are available for these neuropathies. Correction of metabolic derangement is fundamental, as shown by the amelioration of peripheral nerve function obtained after successful simultaneous pancreas-kidney transplantation. The therapeuthic potentials of neurotrophins for the prevention and treatment of diabetic neuropathy have to be confirmed in future studies.     

Leprous neuropathies

Once a terrifying disease, leprosy today has a very hopeful prognosis, provided that it is diagnosed early and treated with modern multidrug chemotherapy, any immunological reactions being recognized quickly and controlled well to prevent (further) peripheral nerve damage after commencing treatment. The diagnosis should be considered in all patients who present with peripheral neuropathy and/or anaesthetic skin lesions who come from or have lived in the tropics and subtropics. Although M. leprae cannot yet be grown in vitro, it is readily grown in experimental animals. A complete gene library has been developed, much of the genome mapped and a number species-specific and common mycobacterial antigens identified. The intricacies of the host-parasite relationship, especially of cell-mediated immunity, and of the important immunological reactions of ENL and reversal reaction have been widely investigated. Modern MDT has caused a dramatic fall in prevalence, although the world annual case detection rate remains at around 600,000 new patients, many being at an early stage of the disease. WHO has launched a campaign to eliminate leprosy as a significant public health risk by the 2000 (with a prevalence of less than 1:10 000 population), which may well be achieved in some endemic countries. Leprosy will, however, remain an important cause of peripheral neuropathy for at least several more decades.     

Animal models of neuropathies

Neuropathy in animals is either genetically determined or is provoked by chemical compounds or physical injury. Diabetes in mice and rats may be spontaneous or induced, but a true copy of diabetic neuropathy in man is not yet available. Painful neuropathy occurs after nerve constriction or neuroma formation. A mouse mutant with delayed Wallerian degeneration demonstrates the pivotal role of this process for the regeneration of injured axons. Surprisingly, the neurotoxic effect of cisplatin which is severe in cancer patients has not yet unambiguously been reproduced in animals. Genetically determined diseases in mutants or transgenic animals may affect the myelination of peripheral axons. 'Trembler mice' are deficient in myelin and possibly correspond to CMT IA in man. The relation of sensory neuronopathies in mice, rats and dogs to human diseases is not yet clear. Motor neuronopathies in experimental animals have attracted much interest, because the recent discovery of motoneuronotrophic factors has raised high hopes. Most of the mutants described have not been appropriately studied, and the mouse mutant 'motoneurone disease' (mnd) eventually was found to have Batten's disease. None of the few more thoroughly studied models is probably a copy of human disease, although they may none the less help to test new therapies.     

Chronic immune demyelinating neuropathies

During growth of Streptomyces niveus wild-type in the novobiocin production medium CDM the resistance of mycelia to novobiocin rises from about 25 micrograms/ml to over 200 micrograms/ml. (S. lividans, a novobiocin-sensitive strain, is resistant to approx. 10 micrograms/ml novobiocin.) The initial period of low level resistance extends from the time of inoculation of the culture until approx. 70 h when the culture is still in the growth phase. High level resistance is initiated before the start of novobiocin production and rises rapidly to a maximum level beyond the end of the growth phase. The rise in pH of the unbuffered CDM medium which occurs during S. niveus fermentation was shown not to be the cause of the change in novobiocin resistance. However, mycelia-free CDM from S. niveus cultures expressing high level novobiocin resistance was shown to contain a factor which induced high level novobiocin resistance in germinating S. niveus spores. Kinetic studies revealed that the inducer first appears in the culture medium before the switch to high level resistance begins and reaches its highest concentration before resistance reaches its maximum level.     

Monoclonal immunoglobulins

In this review, three topics on monoclonal Ig will be discussed. First, the familial occurrence of Waltenstr?m's macroglobulinemia; second, the biologic features which distinguish benign monoclonal IgM and actual Waldenstr?m's macroglobulinemia; third, the diseases which are strongly associated with monoclonal Ig.     

Transformation of serum immunoglobulins and monoclonal antibodies into polyreactive immunoglobulins

It was shown that polyreactive properties of natural serum immunoglobulins or some monoclonal antibodies (i.e. their ability of binding to various antigenically dissimilar antigens) can be induced by the treatment with chaotropic ions (3.5 M KSCN, 5-30 min at 20 (C). Such transformation of monoclonal antibodies or serum immunoglobulins into polyreactive immunoglobulins (PRIG) seems to result of the changes in immunoglobulin conformation but is not from their unblocking. Interaction of PRIG with some antigens immobilized on the plate is strongly dependent on temperature unlike that of monospecific antibodies.     

Secretory immunoglobulins in colonic neoplasms

1. The phosphonium analogues of choline, phosphorylcholine, CDPcholine and phosphatidylcholine were synthesized chemically and characterized by 1H-NMR and 31P-NMR; in 1,2-distearoyl-DL-glycero-3-phosphorylphosphocholine, the 31P-NMR chemical shift of phosphonium relative to phosphate was--28.2 ppm. 2. A comparison was made of the rates of reaction of choline kinase, cholinephosphate cytidyltransferase, cholinephosphotransferase and phospholipase C on natural and phosphonium substrates. Enzyme reaction rates were similar for all but the cytidyltransferase, which exhibited a 3-fold preference for the normal substrate. 3. Weanling rats were maintained for 6 weeks on a diet in which choline was fully replaced by phospho[1,2-14C2]choline mixed with a trace of [Me-3H] choline. Incorporation of phosphocholine into liver lipids was detectable by 31P-NMR even in crude tissue homogenates. Choline-based phospholipids of liver, kidney, lung and brain were extracted, and phosphocholine incorporation calculated from 31P-NMR peak area ratios. The phosphatidylcholine analogues were separated by preparative thin-layer chromatography. Incorporation of phosphocholine ranged from 33% in lung phosphatidylcholine to 6% in kidney sphingomyelin. Variations in 14C/3H ratio between feed and phospholipid extracts indicated preferences for exogenous choline over phosphocholine varying from 1.3: 1 in brain to 3.2: 1 in liver. The results indicated that phosphocholine is a potentially useful 31P-NMR probe for the study of membrane lipids.     

Fractionation of fowl immunoglobulins

Serum, Na2SO4-precipitated serum immunoglobulins and bile from 12-week-old fowls, and serum from day-old chicks, were fractionated by Sephadex G-200 gel filtration, DEAE Sephadex A-50 ion exchange chromatography and ultracentrifugation through 10-40 per cent sucrose gradients. Elution of IgM, IgG, IgA and albumin was monitored by examination of fractions in agar gel diffusion against antisera specific to these proteins. Serum and bile from 12-week-old fowls contained IgM and IgA in two molecular sizes and a single molecular size of IgG. Day-old chick serum contained IgM estimated to be 7S, a polymerised form of IgG in addition to the normal 7S component, and a small molecular weight protein antigenically related to IgA. Most of the albumin in bile was of lower molecular weight than serum albumin, while heavy forms of albumin were detected in ultracentrifugation of bile and day-old chick serum.     

Peripheral neuropathies in childhood: a neuropathological approach

Familial persistent hyperinsulinemic hypoglycemia of infancy is a disorder of glucose homeostasis and is characterized by unregulated insulin secretion and profound hypoglycemia. Loss-of-function mutations in the second nucleotide-binding fold of the sulfonylurea receptor, a subunit of the pancreatic-islet beta-cell ATP-dependent potassium channel, has been demonstrated to be causative for persistent hyperinsulinemic hypoglycemia of infancy. We now describe three additional mutations in the first nucleotide-binding fold of the sulfonylurea-receptor gene. One point mutation disrupts the highly conserved Walker A motif of the first nucleotide-binding-fold region. The other two mutations occur in noncoding sequences required for RNA processing and are predicted to disrupt the normal splicing pathway of the sulfonylurea-receptor mRNA precursor. These data suggest that both nucleotide-binding-fold regions of the sulfonylurea receptor are required for normal regulation of beta-cell ATP-dependent potassium channel activity and insulin secretion.