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Anti-GM2 antibodies are associated with acute cytomegalovirus infection in patients with Guillain-Barré syndrome.1 2Irie et al 1 reported that anti-GM2 antibodies do not bind toN-acetylgalactosaminyl GD1a (GalNAc-GD1a), a terminal trisaccharide identical to that of GM2. Jacobs et al 2 did not test whether IgM anti-GM2 antibodies react with GalNAc-GD1a. By contrast, Kusunoki et al 3 reported that a patient with Guillain-Barré syndrome had IgM antibody activity against both GalNAc-GD1a and GM2, but in whom no result of anti-CMV antibody was shown. We had a patient with Guillain-Barré syndrome subsequent to acute cytomegalovirus hepatitis who had IgM antibodies both to GM2 and GalNAc-GD1a. We investigated whether the IgM anti-GM2 antibodies cross react with GalNAc-GD1a.
Three days after an episode of stomatitis, a 32 year old man noticed left sided facial weakness and dysaesthesia distally in his feet. Over a day, the facial weakness extended to the right side and dysaesthesia progressed to the limbs. He developed progressive weakness of the limbs on day 4, and the next day was unable to stand. On day 5, the patient presented with facial diplegia, severe limb weakness, and moderate reduction of superficial sensation distally in all four limbs. The respiratory muscles were slightly affected. Deep tendon reflexes were absent. Liver enzyme concentrations were raised slightly. Protein concentration in CSF was 109 mg/dl and cellularity was normal. High IgM anti-CMV antibody titres were found in both serum and CSF by enzyme linked immunosorbent assay (ELISA). An electrophysiological study suggested that the predominant process was demyelination involving the motor nerves. Right ulnar sensory nerve action potential was absent. Visser et al 4 reported that patients with Guillain-Barré syndrome with associated cytomegalovirus were young and often developed severe sensory loss with facial nerve involvement and respiratory insufficiency. They also reported a strong correlation between cytomegalovirus infection and severe sensory loss. The clinical manifestations in our patient were similar to those reported by Visser et al.
Thin layer chromatography with immunostaining showed that the serum IgM from our patient reacted strongly with GM2 and GalNAc-GD1a, but not with GM1, GD1a, GD1b, or GT1b (fig 1). ELISA confirmed that his serum had high titres of IgM antibodies to GM2 (1:25 600) and to GalNAc-GD1a (1:12 800) on day 4. Plasmapheresis was performed on days 5, 8, 24, 27, and 29, he was able to walk without assistance on day 60, but his facial diplegia showed slow improvement. The IgM anti-GM2 (1:800) and anti-GalNAc-GD1a (1:400) titres in this patient were significantly reduced on day 39. In the absorption study his serum was added to separate wells coated with individual ganglioside antigens (GM2, GalNAc-GD1a, GM1, and GD1a). The absorption rate was calculated from (1−(optical density at 492 nm in the well with serum with absorption treatment)/(optical density in the reference well with serum without absorption treatment)). No IgM anti-GM2 antibody was absorbed by GM1 or GD1a (fig 2). By contrast, IgM anti-GM2 antibody was absorbed by GalNAc-GD1a. Larger studies are needed to confirm whether (1) some patients with Guillain-Barré syndrome after CMV infection have IgM anti-GalNAc-GD1a antibody and (2) that the anti-GalNAc-GD1a antibodies cross react with GM2.
This research was supported in part by grants in aid from the Ono Medical Research Foundation, Uehara Memorial Foundation, Ciba-Geigy foundation (Japan) for the Promotion of Science, the Nakabayashi Trust for ALS Research, the Ryoichi Naito Foundation for Medical Research, and a Research Grant for Neuroimmunological Diseases from the Ministry of Health and Welfare of Japan.
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