Non-neural-specific T lymphocytes can orchestrate inflammatory peripheral neuropathy.

Neural-specific T lymphocytes are held to play a pathological role in inflammatory peripheral nerve disorders such as the Guillain-Barré syndrome (GBS) and chronic inflammatory demyelinating polyneuropathy (CIDP). Here, non-neural-specific T-cell-mediated inflammation was studied in peripheral nerves in Lewis rats by systemic transfer of ovalbumin-specific activated T cells followed by intraneural injection of ovalbumin. Rapid endoneurial perivenular infiltration of alpha beta T cells and ED1+ macrophages occurred with ovalbumin injection following transfer of 2 x 10(6) T cells. This cellular infiltration and accumulation produced marked increases in blood-nerve barrier (BNB) permeability. In contrast, control casein injections produced neither significant cell accumulation nor BNB permeability changes. Transfer of a higher number of T cells (5 x 10(6)) induced severe Wallerian degeneration and nerve conduction failure in ovalbumin injected nerves. Fewer T cells (5 x 10(5)) induced conduction block and mild demyelination which were markedly augmented by systemic cotransfer of anti-myelin immunoglobulin. This study demonstrates that activated T cells of non-neural specificity can accumulate in peripheral nerve, produce dramatic changes in BNB permeability and with intravenous anti-myelin antibody orchestrate primary demyelination or axonal degeneration in a dose-dependent fashion.

Failure of anti-GM1 IgG or IgM to induce conduction block following intraneural transfer.

In order to confirm the reported pathogenicity of human antibodies to monosialoganglioside GM1, immunoglobulin fractions with high anti-GM1 IgG or IgM titers were prepared from patients with Guillain-Barré syndrome and multifocal motor neuropathy respectively. These fractions were injected intraneurally into rat tibial nerves with fresh human complement. Neither the anti-GM1 IgG nor the anti-GM1 IgM fraction induced significant focal conduction block or slowing compared to a pooled fraction prepared from 5 normal individuals. In contrast, rabbit experimental allergic neuritis serum included as a positive control was highly active. Transverse sections of injected nerve failed to show evidence of demyelination. Staining for human immunoglobulin in cryostat sections showed the presence of injected anti-GM1 antibody bound to nodes of Ranvier up to 6 days following intraneural transfer. These data fail to confirm previous reports of conduction block from intraneural transfer of anti-GM1 serum and suggest that such electrophysiological effects may be the result of factors other than or in addition to anti-GM1 antibodies.

Activated T cells of nonneural specificity open the blood-nerve barrier to circulating antibody.

Recent studies from our laboratory and by other investigators have shown that autoreactive CD4+ cells specific for peripheral nerve P2 protein have a powerful effect on blood-nerve barrier permeability. In this study we injected CD4+ T cells reactive to a nonneural antigen (ovalbumin) systemically and achieved their accumulation in the tibial nerve of Lewis rats by previous intraneural injection of ovalbumin. Selected rats were given systemic demyelinating antibody (antigalactocerebroside) to provide an indicator of changes in the permeability of the blood-nerve barrier, and the animals were monitored by sequential neurophysiological studies and histology. Circulating ovalbumin-specific T cells accumulated at sites of intraneural ovalbumin injection without inducing demyelination in control animals. In rats with circulating galactocerebroside antibodies, local conduction block and demyelination were seen in the region of T-cell accumulation. Electron microscopy demonstrated dissolution of some tight junctions between endothelial cells in areas of T-cell accumulation, and T cells traversing the endothelium between endothelial cells and through their cytoplasm. Endothelial cell damage was evident in these areas. This study demonstrates breakdown of the blood-nerve barrier by activated T cells, even of nonneural specificity, allowing the development of focal conduction block and demyelination in the presence of circulating antimyelin antibodies.

Immunopathogenesis and treatment of the Guillain-Barré syndrome--Part I.

The etiology of the Guillain-Barré syndrome (GBS) still remains elusive. Recent years have witnessed important advances in the delineation of the mechanisms that may operate to produce nerve damage. Evidence gathered from cell biology, immunology, and immunopathology studies in patients with GBS and animals with experimental autoimmune neuritis (EAN) indicate that GBS results from aberrant immune responses against components of peripheral nerve. Autoreactive T lymphocytes specific for the myelin antigens P0 and P2 and circulating antibodies to these antigens and various glycoproteins and glycolipids have been identified but their pathogenic role remains unclear. The multiplicity of these factors and the involvement of several antigen nonspecific proinflammatory mechanisms suggest that a complex interaction of immune pathways results in nerve damage. Data on disturbed humoral immunity with particular emphasis on glycolipid antibodies and on activation of autoreactive T lymphocytes and macrophages will be reviewed. Possible mechanisms underlying initiation of peripheral nerve-directed immune responses will be discussed with particular emphasis on the recently highlighted association with Campylobacter jejuni infection.

Immunopathogenesis and treatment of the Guillain-Barré syndrome--Part II.

In the second part of our review the role of antecedent infections in the pathogenesis of GBS is discussed. The association with Campylobacter jejuni (C. jejuni) is highlighted and the concept of molecular mimicry, i.e., sharing of epitopes between microbes and peripheral nerve, explained. Alternative mechanisms to relate an infection with the immune-mediated neuropathy are elaborated. Current therapies of the GBS include plasma exchange, high-dose intravenous immunoglobulins, and supportive treatment directed to secondary complications. Published therapeutic trials are reviewed and future approaches are outlined. Principles of general care are also summarized.

Effects of mast cell degranulation on blood-nerve barrier permeability and nerve conduction in vivo.

Changes in blood-nerve barrier (BNB) integrity and nerve conduction were assessed in rat tibial nerves in which mast cell degranulation was induced by intraneural injection of Compound 48/80 (C48/80). BNB permeability changes were quantitated by the endoneurial accumulation of Evan's blue-labelled albumin (EBA). Over 24 h following intraneural injections, nerves receiving saline showed a 6-fold increase in endoneurial extravasated EBA compared to non-injected nerves. Injection of 250 ng C48/80 produced a similar level of EBA accumulation as saline injections. Increasing the C48/80 dose to 1 microgram produced twice the EBA accumulation as control saline injections and a 12-fold increase over non-injected nerves. Tibial nerves injected with these C48/80 doses showed completely normal nerve conduction. In contrast, increasing the dose to 5 micrograms C48/80 induced, again, increased EBA accumulation over lower doses, but also significant axonal degeneration indicated by profound decreases in compound muscle action potential amplitudes measured with nerve stimulation distal to the injection site. Co-injection of Leupeptin and neutralizing anti-TNF-alpha antibodies with C48/80 failed to mitigate conduction abnormalities suggesting a direct toxic effect of C48/80 on nerve fibres. Time-kinetic studies showed rapid restoration of BNB integrity 24-48 h after injections in all nerves, but at these timepoints C48/80 injected nerves still showed significantly increased BNB permeability compared to nerves injected with saline. Neural mast cell stimulation in the absence of a primed immune response can produce profound temporary changes in blood-nerve barrier permeability and endoneurial fluid composition without affecting nerve conduction.

Peripheral nervous system demyelination from systemic transfer of experimental allergic neuritis serum.

The ability of systemically transferred experimental allergic neuritis (EAN) serum to produce EAN lesions in recipient animals was studied. Seventeen Lewis rats received five daily 1-ml intraperitoneal (i.p.) injections of sera from rabbits with EAN induced with bovine myelin/complete Freund's adjuvant (CFA). Another 17 rats received similar injections of sera from rabbits inoculated with CFA alone. On day 0 (the first day of i.p. injections), all rats were injected in the proximal tibial branch of the right sciatic nerve with a single 10-microliters injection of 0.03 M 5-hydroxytryptamine (5-HT) in sterile 0.15 M saline. Proximal tibial branches of left sciatic nerves received similar single injections of saline alone. Animals were then studied using electrophysiological and histological techniques. In all animals, intraneural saline injection had no significant effect upon nerve conduction. In the presence of circulating CFA serum, 5-HT injection caused a mild gradual decrease in amplitude ratio becoming maximal by day 17 (P < 0.005) and partially resolving by day 28. In contrast, in the presence of circulating EAN serum, 5-HT injection caused a more rapid and severe decrease in amplitude ratio becoming maximal by days 6-10 (P < 0.001 day 6; P < 0.0001 day 10) and completely resolving by day 28. Histological analysis of nerves injected with 5-HT in CFA serum-treated animals showed areas of mild demyelination, axonal degeneration and some fibre loss consistent with needle trauma. In contrast, 5-HT-injected nerves in animals administered EAN serum showed areas of marked cellular infiltration and severe demyelination in association with numerous debris-filled infiltrating cells.(ABSTRACT TRUNCATED AT 250 WORDS)

Patterns of conduction impairment in experimental allergic neuritis. An electrophysiological and histological study.

Electrophysiological and histological studies of peripheral nerve were performed in 24 Lewis rats with experimental allergic neuritis (EAN) in which disease had been induced by a single myelin and adjuvant inoculation in one footpad. Demyelination was demonstrated in transverse nerve sections from ventral roots, proximal sciatic nerves and also in distal plantar nerves. Histological and electrophysiological assessments showed that injected limbs were more affected than uninjected limbs. Neurophysiological studies demonstrated two distinct patterns of conduction failure based upon proximal/distal compound muscle action potential (CMAP) amplitude ratios in both uninjected and injected limbs. Slightly more than half of all nerve trunks showed a mildly reduced distal CMAP amplitude irrespective of stimulus origin. The rest displayed a more severe reduction of distal amplitude that was length-dependent, becoming smaller with proximal stimulation. Histological lesions in plantar nerves were often more severe than those in proximal sciatic nerves or ventral roots. Axonal degeneration was an uncommon finding. This study has demonstrated patterns of peripheral nerve conduction impairment similar to those reported in patients with inflammatory demyelinating neuropathy. Moreover, it has shown that a low distal CMAP amplitude may result from demyelination of distal motor nerve segments and not necessarily from axonal degeneration.

IgG immunoadsorption in experimental allergic neuritis: effect on antibody levels and clinical course.

The effect of IgG immunoadsorption upon the course of chronic experimental allergic neuritis (EAN) is described. Miniature membrane plasma separators coupled with a Protein A (PA)-Sepharose immunoadsorbent column were used to perform upon conscious rabbits 5 IgG immunoadsorption treatments over 6 days. Quantitation of anti-myelin IgG and IgM by ELISA revealed that 55-65% of plasma IgG was removed per treatment. Rapid post-treatment antibody rebound was observed for anti-myelin IgG although no antibody overshoot above control levels could be observed. Anti-myelin IgM levels remained relatively unaffected by PA immunoadsorption. Comparisons of clinical scores between control and treatment animals showed that IgG immunoadsorption was significantly beneficial (day 1 post-treatment p less than 0.001; day 2 post-treatment p less than 0.05). However, rapid relapse was observed in all treatment animals such that by day 3 post-treatment no significant clinical difference between control and treatment groups could be observed. IgG immunoadsorption suppresses the clinical progression of chronic EAN in a manner similar to that seen with plasma exchange. This finding suggests that antibody modulates early disease pathogenesis.

Experimental allergic neuritis: effect of plasma infusions.

The effect of intravenous fresh frozen plasma (FFP) and artificial plasma infusions upon the clinical course of chronic experimental allergic neuritis (EAN) in the rabbit was investigated. A total of 12 animals allocated to treatment groups received rabbit FFP or a gelatin plasma expander Haemaccel (Hoechst) and were compared to 13 control non-treated animals. Animals receiving Haemaccel at a rate of 15 ml/kg/day for 7 days showed no significant clinical benefit at any stage. However, animals receiving 15 ml/kg/day FFP for 8 days showed significant clinical benefit during treatment initiated at the onset of definite neurological symptoms of EAN (Mann-Whitney U test, day 4 post-allocation P less than 0.05; day 6 post-allocation P less than 0.01; day 8 post-allocation P less than 0.05). Relapse was observed after cessation of treatment such that comparisons of clinical scores at day 14 and 22 post-allocation revealed no significant differences. Analysis of plasma anti-myelin IgG levels by ELISA showed that non-immunogenic plasma volume expansion decreased anti-myelin IgG concentrations immediately by an average of 34% but had no long-term effect. In contrast, anti-myelin IgG concentrations in FFP infused animals were significantly decreased, compared to controls, when measured 24 h after the last infusion (Student's t-test P less than 0.05). Identical percentage weight losses for both control and treatment groups post-allocation indicated that this decrease was immunologically mediated and not due to plasma dilution. Similar plasma cortisol concentrations measured in both groups showed no significant artifactual induction of endogenous steroid production. Infusions of FFP during early disease progression are able to mediate clinical remission in animals with chronic EAN.

Membrane plasma exchange in experimental allergic neuritis: effect on antibody levels and clinical course.

The effect of membrane plasma exchange on the course of chronic experimental allergic neuritis in rabbits is described. Using miniature membrane plasma separators conscious animals were treated with 4 exchanges over 5 days removing one plasma volume per procedure and using a non-immunogenic gelatin plasma solution as replacement. Comparisons of clinical scores between control and treated groups indicated that treated animals received significant benefit from plasma exchange (day 1 post-treatment P less than 0.002; day 3 post-treatment P less than 0.01). However, relapse was observed in all plasma exchanged animals such that by day 8 post-treatment there was no significant difference in clinical scores between the two groups. Quantitation of anti-myelin IgG and IgM by ELISA assay showed that 55-60% of circulating antibody was removed per exchange. Rapid post-exchange antibody rebound was observed for both IgG and IgM so that pre-exchange levels were re-established within 24-48 h. However, no significant overshoot in circulating levels of anti-myelin IgG nor IgM could be observed. It is probable that long-term remission as a result of therapeutic plasma exchange is a function of effective circulating plasma removal and if present, the suppression of ongoing antigenic stimuli.

Chronic experimental allergic neuritis. An electrophysiological and histological study in the rabbit.

Ten adult outbred New Zealand white rabbits were inoculated with a single multiportal dose of purified bovine peripheral nerve myelin and Freund's adjuvant containing 500 mg of nerve antigen. Seven animals developed chronic relapsing or progressive disease which was followed by clinical examination for 14 months. Electrophysiological studies showed marked slowing of motor conduction velocity, dispersion of the evoked muscle action potential (MAP) and reduction in amplitude of the MAP derived from distal stimulation. Histological examination of the peripheral nervous system showed at 12 months a marked hypertrophic neuropathy in the nerve roots with well developed onion bulbs, active demyelination and a moderate nerve fibre loss. It is suggested that these animals provide a reliable and predictable model for human chronic inflammatory demyelinating polyneuropathy (CIDP) which should prove valuable for therapeutic trials and studies of pathogenetic mechanisms.

Linear response curves from an ELISA assay: measurement of anti-myelin IgG and IgM during experimental allergic neuritis.

An ELISA method for generating linear dose-response curves for measuring anti-myelin IgG and IgM is described. Linearity is achieved without logarithmic transformations. This test is used to measure plasma levels of anti-myelin antibodies in rabbits with EAN. Results are expressed as relative concentrations of antibody in arbitary mass units with 95% confidence limits fitted by inverse prediction. In the 8 animals studied, appearance of anti-myelin antibody always preceded onset of clinical signs and neither anti-myelin IgG nor IgM could be detected in any animal pre-inoculation. Five out of 8 animals displayed steady and progressive increases in anti-myelin IgG with the remaining 3 animals showing plateaus in IgG levels 21-30 days post-inoculation. Increases in anti-myelin IgG were generally parallelled by increases in disease severity. However, 2 animals showed recovery and relapse from EAN with no change in plasma levels of anti-myelin IgG. Patterns of production of anti-myelin IgM varied with some animals displaying early peaks while others showed gradual increases.