Editors' Note: An International Perspective on Preceding Infections in Guillain-Barré Syndrome: The IGOS-1000 Cohort
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Dr. Leonhard et al. analyzed the presence of several recent bacterial and viral infections in 768 patients included in the International Guillain-Barré syndrome (GBS) Outcome Study (IGOS) with available biosamples. They found serologic evidence of a recent infection with Campylobacter jejuni in 228 patients (30%), Mycoplasma pneumoniae in 77 (10%), hepatitis E virus in 23 (3%), cytomegalovirus in 30 (4%), and Epstein-Barr virus in 7 (1%), but interestingly, the proportion of patients reporting symptoms of antecedent infections did not significantly differ between those testing positive or negative for these recent infections. The authors found that the distribution of infections was similar across geographic regions, but the association between infection and clinical phenotype differed. The sensorimotor variant and demyelinating electrophysiologic subtype were most frequent across all infection groups, and the Campylobacter jejuni–positive patients were more severely affected. Among Campylobacter jejuni–positive patients, the pure motor variant and axonal electrophysiologic subtype were more frequent in Asian compared with American or European patients. The authors concluded that broad serologic testing of patients with GBS was important to identify the most likely infectious triggers, given the mismatch between symptom reporting and serologic results, and noted that these infections can have value in future prognostic models. In response, Drs. Debnath and Nagappa noted that most patients in this study were from temperate regions, pointing to the high prevalence of arboviral infections (not tested in this study) such as dengue, chikungunya, Japanese encephalitis, and Zika virus in the tropics, which have been associated with GBS in prior studies. In particular, they cited their recent study from India in which 66.7% of patients were seropositive for chikungunya vs 32% for Campylobacter jejuni. They called for studies with broader infection panels including arboviruses, increased representation of patients with GBS from tropic countries, and simultaneous testing of contemporary population controls. Responding to these comments, the authors agreed that the results of their study do not reflect GBS statistics worldwide, but noted that they found similar distributions of their 5 study pathogens across participating countries including Bangladesh, Malaysia, and Japan. They pointed out that 45% of controls in the aforementioned Indian study also had evidence of chikungunya while the proportion of dengue and Japanese encephalitis virus was lower in patients than controls and noted that the high proportion of patients with evidence of multiple infections (66% vs 6% in IGOS) may reflect cross-reactive antibodies due to other prior Flavivirus infection or vaccination. They agreed that controlled studies with international collaboration will be important to better identify GBS-associated infections. This discussion highlights the geographic and methodological complexities involved in studying the interplay between infections and the development of GBS.
Dr. Leonhard et al. analyzed the presence of several recent bacterial and viral infections in 768 patients included in the International Guillain-Barré syndrome (GBS) Outcome Study (IGOS) with available biosamples. They found serologic evidence of a recent infection with Campylobacter jejuni in 228 patients (30%), Mycoplasma pneumoniae in 77 (10%), hepatitis E virus in 23 (3%), cytomegalovirus in 30 (4%), and Epstein-Barr virus in 7 (1%), but interestingly, the proportion of patients reporting symptoms of antecedent infections did not significantly differ between those testing positive or negative for these recent infections. The authors found that the distribution of infections was similar across geographic regions, but the association between infection and clinical phenotype differed. The sensorimotor variant and demyelinating electrophysiologic subtype were most frequent across all infection groups, and the Campylobacter jejuni–positive patients were more severely affected. Among Campylobacter jejuni–positive patients, the pure motor variant and axonal electrophysiologic subtype were more frequent in Asian compared with American or European patients. The authors concluded that broad serologic testing of patients with GBS was important to identify the most likely infectious triggers, given the mismatch between symptom reporting and serologic results, and noted that these infections can have value in future prognostic models. In response, Drs. Debnath and Nagappa noted that most patients in this study were from temperate regions, pointing to the high prevalence of arboviral infections (not tested in this study) such as dengue, chikungunya, Japanese encephalitis, and Zika virus in the tropics, which have been associated with GBS in prior studies. In particular, they cited their recent study from India in which 66.7% of patients were seropositive for chikungunya vs 32% for Campylobacter jejuni. They called for studies with broader infection panels including arboviruses, increased representation of patients with GBS from tropic countries, and simultaneous testing of contemporary population controls. Responding to these comments, the authors agreed that the results of their study do not reflect GBS statistics worldwide, but noted that they found similar distributions of their 5 study pathogens across participating countries including Bangladesh, Malaysia, and Japan. They pointed out that 45% of controls in the aforementioned Indian study also had evidence of chikungunya while the proportion of dengue and Japanese encephalitis virus was lower in patients than controls and noted that the high proportion of patients with evidence of multiple infections (66% vs 6% in IGOS) may reflect cross-reactive antibodies due to other prior Flavivirus infection or vaccination. They agreed that controlled studies with international collaboration will be important to better identify GBS-associated infections. This discussion highlights the geographic and methodological complexities involved in studying the interplay between infections and the development of GBS.
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Author disclosures are available upon request (journal{at}neurology.org).
- © 2023 American Academy of Neurology
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