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Lymphotoxin (LT) is widely regarded as a proinflammatory cytokine with activities equivalent to tumor necrosis factor (TNF). The contribution of LT to experimental autoimmune encephalomyelitis (EAE) was examined using TNF/LTalpha-/- mice, TNF-/- mice, and a new LTalpha-/- line described here. All mice were generated directly in the C57BL/6 strain and used for the preparation of radiation bone marrow chimeras to reconstitute peripheral lymphoid organs and restore immunocompetence. This approach overcame the problems related to the lack of lymph nodes that results from LTalpha gene targeting. We show here that when LT is absent but TNF is present, EAE progresses normally. In contrast, when TNF is absent but LT is present, EAE is delayed in onset and inflammatory leukocytes fail to move normally into the central nervous system parenchyma, even at the peak of disease. In the absence of both cytokines, the clinical and histological picture is identical to that seen when TNF alone is deficient, including demyelination. Furthermore, the therapeutic inhibition of TNF and LTalpha with soluble TNF receptor in unmanipulated wild-type or TNF-/- mice exactly reproduces these outcomes. We conclude from these studies that TNF and LT are functionally distinct cytokines in vivo, and despite sharing common receptors, show no redundancy of function nor mutual compensation.

The role of cyclosporin A (CsA) in the treatment of resistant chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) was retrospectively reviewed in 19 patients who had failed to respond adequately to corticosteroids, plasmapheresis, intravenous immunoglobulin, and in some cases other immunosuppressive agents. Patients were subdivided into progressive or relapsing types according to the course of disease and response to therapy graded at follow-up by clinical and electrophysiological criteria. In the progressive group, the mean disability status declined from 3.8+/-0.7 to 1.8+/-1.1 grades on a 5-grade scale following CsA therapy (P<0.001). In the relapsing group, the mean annual incidence of relapse declined from 1.0+/-0.5 to 0.2+/-0.4 after commencement of CsA (P<0.05). Dose-dependent, reversible nephrotoxicity was the most serious complication of therapy, and necessitated cessation of CsA in 2 patients. In conclusion, CsA is an efficacious and, with appropriate monitoring, safe therapy for patients with CIDP.

We report a family with Noonan syndrome (NS), giant proximal nerve hypertrophy, and hereditary motor sensory neuropathy type 1A (HMSN1A). Five members of a family were found to have clinical features of NS. In all cases, NS was associated with giant hypertrophy of proximal nerves and two individuals also exhibited café-au-lait spots. In one case, an 8-to-10-cm diameter pelvic mass was shown to be a grossly hypertrophied nerve, with histologic features of demyelination and remyelination. In addition, four of five family members affected with NS were found to have HMSN1A clinically and by demonstration of constitutional HMSN1A duplication on DNA testing. Linkage analysis for NS ruled out the involvement of the neurofibromatosis type 1 gene and the known NS locus in chromosome 12, supporting the existence of an additional NS locus.

The two most common subtypes of Charcot-Marie-Tooth (CMT) disease are CMT1A and CMTX1. To determine whether these different genetic entities display different morphological phenotypes we compared sural nerve biopsies of CMT1A patients due to PMP22 duplication with biopsies of CMTX1 patients with proven Connexin32 mutations. In CMT1A nerve biopsies we found a severe reduction in myelinated fiber density, hypermyelination as well as demyelination, and a high percentage of onion bulb formations. CMTX1 nerve biopsies showed significant differences: a higher myelinated fiber density, thinner myelin sheaths, more cluster formations, and only few onion bulb formations. Teased fibers studies in CMT1A patients showed features of demyelination and/or remyelination in almost all fibers. In contrast, teased fibers of CMTX1 patients were uniformly thinly myelinated with 5-10% active axonal degeneration and 15% segmental demyelination. Median nerve motor conduction velocities were significantly faster in CMTX1 patients (31.6+/-5.5 m/s) than in CMT1A patients (18.2+/-6.9 m/s). The possible roles of PMP22 and Connexin32 in the pathogenesis of CMT are discussed.

Tumor necrosis factor (TNF)-dependent sites of action in the generation of autoimmune inflammation have been defined by targeted disruption of TNF in the C57BL/6 mouse strain. C57BL/6 mice are susceptible to an inflammatory, demyelinating form of experimental autoimmune encephalomyelitis (EAE) induced by the 35-55 peptide of myelin oligodendrocyte glycoprotein. Direct targeting of a strain in which EAE was inducible was necessary, as the location of the TNF gene renders segregation of the mutated allele from the original major histocompatibility complex by backcrossing virtually impossible. In this way a single gene effect was studied. We show here that TNF is obligatory for normal initiation of the neurological deficit, as demonstrated by a significant (6 d) delay in disease in its absence relative to wild-type (WT) mice. During this delay, comparable numbers of leukocytes were isolated from the perfused central nervous system (CNS) of WT and TNF-/- mice. However, in the TNF-/- mice, immunohistological analysis of CNS tissue indicated that leukocytes failed to form the typical mature perivascular cuffs observed in WT mice at this same time point. Severe EAE, including paralysis and widespread CNS perivascular inflammation, eventually developed without TNF. TNF-/- and WT mice recovered from the acute illness at the same time, such that the overall disease course in TNF-/- mice was only 60% of the course in control mice. Primary demyelination occurred in both WT and TNF-/- mice, although it was of variable magnitude. These results are consistent with the TNF dependence of processes controlling initial leukocyte movement within the CNS. Nevertheless, potent alternative mechanisms exist to mediate all other phases of EAE.

The clinical, electrophysiological and pathological features and prognosis of 25 patients with vasculitis selectively affecting the peripheral nervous system were evaluated. Although most patients had a history of mononeuritis multiplex or an asymmetrical neuropathy six out of 25 had a symmetrical neuropathy, both clinically and on neurophysiological testing, by the time of presentation. There were no signs of accompanying systemic vasculitis in any of the patients and serological abnormalities were limited to an elevated erythrocyte sedimentation rate (ESR) in nine out of 21 patients and low titre anti-nuclear antibodies in four out of 20 patients. Most patients had a necrotizing vasculitis on nerve biopsy, although in some cases the diagnosis was made on the association of inflammatory cell infiltrates with extensive axonal degeneration and immune complex deposition on immunofluorescence studies. The mean time from symptom onset to diagnosis was 46 weeks. All patients were treated with corticosteroids and most with additional immunosuppressive therapy. In contrast to vasculitic neuropathy associated with systemic vasculitis the prognosis was good with 24 out of 25 survivors at a mean of 176 weeks follow-up having a mean improvement of 1.4 units on a six-point disability scale.

The RNA world hypothesis is founded on the idea of an RNA replicase, or self-replicating RNA molecule, and presupposes the later emergence of ribozymes capable of catalyzing the synthesis of peptides. The recent demonstrations of ribozyme-catalyzed template-directed primer extension, and of ribozyme-catalyzed amide bond synthesis, confirm the plausibility of the RNA world, and highlight the steps that remain to be demonstrated in the laboratory.

The Schwann cell or its myelin membrane appears to be the focus of autoimmune attack in several peripheral neuropathies. Potential Schwann cell antigens have therefore been extensively studied. Of the known Schwann cell proteins, MBP, P2, MAG, PLP, PO, PMP-22 and Connexin 32, gene defects of the latter three have recently been shown to be responsible for some forms of hereditary sensory and motor neuropathies. The L2/HNK-1 epitope, common to MAG, Po and PMP-22, is the target of autoantibody damage in neuropathies associated with certain IgM paraproteinaemias. P2, the inciting antigen in rat EAN, has no demonstrated role in human neuropathies. The same appears true for the glycolipid galactocerebroside, a neuritogen in rabbits. Gangliosides are currently under intense study, but the antigen for the common inflammatory neuropathies remains undefined. Evidence for the potential role of Schwann cells in immune modulation is provided; Schwann cells produced MHC molecules, the adhesion molecules I-CAM1, L1, L2-HNK-1, Ng-CAM, N-cadherisn, the cytokines IL-1, IL-6 and TNF-alpha and the inflammatory prostanoids, PGE-2 AND TxA2.

Experiments were conducted to investigate the effect of activated T cells on the blood-nerve barrier (BNB) in experimental allergic neuritis (EAN). T cells reactive to the P2 component of myelin (P2 T cells) and known to cause EAN were injected into the sciatic nerve of Lewis rats. Animals were then given daily intraperitoneal (i.p.) injections of serum with known demyelinating activity (rabbit EAN serum) or control serum. Serial nerve conduction studies across the injected segment were performed and nerves were removed at various stages for histology. Focal conduction block and perivascular demyelination were evidence in T cell injected nerves of animals treated with EAN serum. In animals treated with control serum no conduction block was seen and only perivascular infiltrates without demyelination were present. Similar results were obtained with T cells reactive to non-neural antigens, although the effect was less marked. Systemically administered rabbit immunoglobulin (Ig) was demonstrated within the endoneurium of P2 T cell injected nerves by immunofluorescence and the endoneurial blood vessels showed increased permeability to circulating horseradish peroxidase (HRP). These findings demonstrate that activated T cells cause focal breakdown of the BNB, allowing circulating antimyelin antibody to enter the endoneurium with consequent focal demyelination. P2 reactive EAN producing T cells do not cause significant demyelination when injected intraneurally (i.n.) in the absence of circulating antimyelin antibody. Intraneural injection of tumour necrosis factor alpha (TNF-alpha) yielded similar results, causing conduction block and perivascular demyelination in the presence of circulating antimyelin antibody but not in control serum treated animals.

Four patients are described who developed sensorimotor neuropathy while being treated with simvastatin and had complete or partial resolution of clinical abnormalities after withdrawal of treatment. In one case onset was within days of commencing treatment, but in two cases symptoms did not develop for two years. The electrophysiological and pathological features of the neuropathy were those of axonal degeneration. Clinical evidence of proximal and distal weakness and muscle fasciculations and persistent abnormalities of sensory conduction after recovery suggest the possibility of toxic damage to anterior horn cells and dorsal root ganglia. Thirty eight other cases with symptoms suggestive of peripheral neuropathy have been reported to the Australian Adverse Drug Reactions Advisory Committee, 22 of whom recovered after cessation of treatment; in five cases there was recurrence after re-exposure to the drug. Simvastatin should be considered among the causes of peripheral neuropathy, and the drug should be withdrawn if patients receiving it develop muscle weakness or sensory disturbances.

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.

Studies were conducted in experimental allergic neuritis (EAN) to evaluate the possible interaction of cellular and humoral immune mechanisms in the demyelinating process. EAN was induced in Lewis rats by passive transfer of T cells reactive to P2 myelin protein or by active immunisation with whole myelin. Animals were then given systemic antimyelin antibody or control serum and assessed clinically, electrophysiologically and with semiquantitative histological studies. Animals given intraperitoneal (i.p.) P2-reactive T cells and systemic antimyelin antibody developed much more severe disease than those given i.p. T cells alone (P < 0.001). In actively immunised animals, the addition of systemic antimyelin antibody did not significantly alter disease severity. We believe the more severe disease in animals receiving T cells and antimyelin antibody reflects synergy between cellular and humoral immune mechanisms whereby neural antigen-specific T cells breach the blood-nerve barrier, allowing demyelinating antibody access to the endoneurium. In EAN induced by active immunisation with whole myelin it is likely that both B and T cell activation occurs and that the more severe demyelination characteristic of this disease reflects the involvement of both humoral and cellular immunity.

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.

Ten-microliters quantities of trypsin or saline were injected into rat tibial nerve and the physiological and histological changes evaluated and compared to the focal demyelinating lesions induced by intraneural injection of rabbit EAN serum and proteinase K. The injection of trypsin produced progressive conduction block that was maximal on day 4, and a slowing of motor nerve conduction. Early retraction of myelin at paranodes, vesicular change, and macrophage stripping of myelin from nerve axons were seen on histological examination. At day 4, the first groups of completely demyelinated axons were seen, typically in a perivascular distribution. These changes were similar to those seen in the positive controls and thus support the postulate that proteolytic enzymes from macrophages--the dominant cellular species within the demyelinating lesion, play a central role in degradation of the myelin sheath in demyelinating diseases.

In studying autoimmune diseases of the human peripheral nervous system (PNS), in vitro studies involving the use of cultured rat Schwann cells, neurons, and disease-inducing immune system cells have provided basic information about disease pathogenesis. For example, T-cells that induce experimental allergic neuritis have been shown in vitro to damage Schwann cells, the target cell in these diseases. However, before making contact with Schwann cells, these T-cells must first pass through the blood-nerve barrier. Despite the importance of this interaction, no studies employing PNS endothelial cells in coculture with dorsal root ganglia cells to mimic the environment of the blood-nerve barrier have been reported. This paper describes a simple method for the isolation and culture of peripheral nerve vascular endothelial cells from adult rats that should facilitate in vitro studies of the blood-nerve barrier. Endothelial cells were identified by their expression of an endothelial cell marker, Factor VIII/von Willebrand factor. Their identity was further confirmed by their inability to express Thy 1.1, a fibroblast marker, and their in vitro morphology. Purity of endothelial cell cultures was ensured by a regular program of Thy 1.1 complement depletion of fibroblasts.

The final mediators of immune injury in EAN were investigated by intraneural injection of sensitized lymphocytes. Unfractionated specifically sensitized cells caused conduction block which was evident within 24 h after injection, reached significance within 3 days and remained depressed for over 12 days. Pathological changes at the site of injection showed infiltrating lymphoid and mononuclear cells and significant demyelination. The latter was only evident several days after the electrophysiological changes. These effects were shown to be specific, as injection of LNC from normal rats or those immunized with CFA alone did not induce the changes. Fractionation of sensitized LNC into the CD4+ and CD8+ subsets of T-cells showed only the former caused a drop in the amplitude ratio of nerve conduction. These changes in conduction were comparable to those observed in rats immunized with myelin/CFA to induce active EAN. Cyclosporin A (CSA) was given to host animals to block production of cytokines by the injected cells. This inhibited macrophage accumulation at the site of injection, but did not stop the electrophysiological changes. This result suggested that there was direct T-cell damage rather than damage consequent upon macrophage activation. These studies developed a model in which the cellular and molecular mechanisms of conduction block and demyelination in EAN can be studied by direct injection of specifically sensitized LNC.

Hereditary neuropathy with liability to pressure palsies (HNPP) has been a associated with a deletion of 1.5 megabases of chromosome 17p. One of four biopsy proven HNPP families that we have studied did not possess this deletion. As the deleted DNA region includes the coding region for a peripheral myelin gene (PMP22), we used single strand conformation analysis to examine this gene for mutations in the non-deleted HNPP family. An abnormal fragment in exon 1 was identified, and sequencing revealed a two base pair deletion in all affected family members. The deletion results in a frame shift, providing strong evidence that this gene has an important role in the pathogenesis of the disease.

Five patients with peripheral neuropathy and benign IgG monoclonal paraproteinemia are reported, all of whom had a sensorimotor neuropathy with a remitting and relapsing course. The serum paraprotein level did not correlate with the patient's clinical status. Electrophsyiological studies showed marked slowing of conduction velocity and conduction block in four of the patients and mild slowing in the other. Sural nerve biopsies demonstrated a demyelinating neuropathy with inflammatory cell infiltrates in each of the five patients. Three of the patients had evidence of myelin/Schwann cell reactivity on immunofluorescence studies and in all nerves dense expression of major histocompatability complex class I and II molecules was evident within the endoneurium, on invading mononuclear cells, endothelial cells and Schwann cells. All the patients responded to treatment, plasmapheresis being particularly effective. Four patients have achieved prolonged remissions after all treatment had ceased. These five cases of peripheral neuropathy and IgG paraproteinaemia were identical in their clinical, electrophysiological and pathological features to patients with chronic inflammatory demyelinating polyneuropathy.

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)

Immunologically incompatible sciatic nerve grafts were inserted into the severed sciatic nerves of Wistar rats. In an attempt to induce graft tolerance, low-dose cyclosporin A (CsA) was administered to some animals for 20 weeks, then gradually withdrawn. Behavioural, electrophysiological and histological studies indicated that some degree of regeneration took place in all animals regardless of treatment. Neither a daily dose of 5 mg/kg nor 10 mg/kg was sufficient to prevent the rejection and subsequent disruption of allograft structure, and as a consequence reinnervation of the distal stump was limited. This was manifest both in the poor functional recovery of the denervated foot, and in the large number of regenerated axons found outside of the perineurial membranes of the transplanted fascicles. Therefore, tolerance was not induced at these doses. Furthermore, the significant decrease in the amplitude of electromyographs recorded from experimental and unoperated (control) animals suggests CsA may have a deleterious effect on unlesioned nerve even at these low doses. It would be prudent, therefore, to exercise caution in the combined use of nerve allografts and CsA immunosuppression, until the neurotoxicity of CsA has been investigated further. This is particularly important since CsA is sometimes used in the treatment of certain neuropathic autoimmune diseases.

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.

Interactions between CD4+ P2-specific T-cell lines and Schwann cells were examined in vitro by scanning electron microscopy (SEM) and T-cell proliferation studies. CD4+ T-cell lines clustered around and attached to Schwann cells which expressed Major histocompatibility complex (MHC) class II molecules. Only those P2-specific T-cell lines capable of inducing experimental allergic neuritis (EAN) when injected into adult Lewis rats clustered around the Schwann cells. T-cell lines responsive to P2 but not able to induce EAN did not cluster around Schwann cells. The addition of exogenous P2 protein inhibited in a dose-dependent way clustering and proliferation of the P2-specific T-cell lines. Cytoplasmic P2 was detected in Schwann cells by immunofluorescent labelling and the results of proliferation assays in this study suggest that endogenous P2 protein was processed by the Schwann cells and presented to T-cell lines in association with MHC class II molecules. The clustering and proliferation of class II-restricted CD4+ P2-specific T-cell lines in the presence of Schwann cells provides evidence for a role for Schwann cells as facultative antigen presenting cells, processing and presenting 'self' endogenous antigen to CD4+ T-cell lines capable of inducing EAN.

The cytotoxic effects of CD4+ P2-specific T-cell lines on Schwann cells were examined in vitro with 51Cr-release cytotoxicity assays. Only those P2-specific T-cell lines capable of inducing EAN when injected back into adult Lewis rats were cytotoxic to the Schwann cells. The addition of exogenous P2 protein was not necessary for the cytotoxic effect. The monoclonal antibody (mAb) OX6 directed against Major histocompatibility complex (MHC) class II molecules blocked cytotoxicity, indicating an essential role for MHC class II molecules in this interaction between CD4+ T-cell lines and Schwann cells.

The clinical, electrophysiological and pathological features and prognosis of 34 patients with peripheral neuropathy caused by necrotizing vasculitis were evaluated. The causes included polyarteritis nodosa and its Churg-Strauss variant, rheumatoid arthritis, undifferentiated connective tissue disease, Wegener's granulomatosis, primary Sjögren's disease, and chronic lymphocytic leukaemia with cryoglobulinaemia; 2 patients had no evidence of systemic vasculitis. Mononeuritis multiplex was the most common clinical manifestation, followed by asymmetrical polyneuropathy and distal symmetrical polyneuropathy. Pain was a frequent symptom. Nerve conduction studies were abnormal in all cases, and in 3 patients there was conduction block or severe slowing of motor conduction. Necrotizing vasculitis was present in sural nerve biopsies of most cases, and severe active axonal degeneration was a dominant feature. Immunofluorescent staining of blood vessels for immunoglobulin, C3 and fibrinogen was positive in all cases in which it was performed, even when there was no cellular infiltration. All patients were treated with prednisone alone or in combination with other immunosuppressive agents, or with plasmapheresis. Long-term follow-up studies demonstrated that although the peripheral neuropathy usually improved and caused only mild to moderate functional disability, the long-term prognosis of the systemic disease was poor with a 5-yr survival of only 37%.

This study examines the modulation of major histocompatibility complex (MHC) expression on Lewis rat Schwann cells (Scs) cultured in the presence of dorsal root ganglion neurons (DRG). MHC class I and II molecules were induced on Scs using recombinant murine interferon-gamma (IFN-gamma), lymph node cells (LNC), removed at day 9 from Lewis rats with experimental allergic neuritis (EAN) and syngeneic T-cell line cells responsive to P2 basic protein. EAN LNC induced MHC class I on Scs but only IFN-gamma or P2-responsive T-cells induced MHC class II. Control LNC from animals injected with Freund's adjuvant alone or naive spleen cells did not induce MHC class II. P2 T-cells clustered in aggregates to the Scs. Similar studies were performed with inhibitors of IFN-gamma; hydrocortisone, cyclosporin A, dibutyryl cyclic AMP, methyl-xanthine and prostaglandin E2. Each agent produced a dose-dependent inhibition of MHC expression and prevented clustering of P2-responsive T-cells to Scs.

The question of whether Cyclosporin A, at the low doses reported to allow survival of nerve allografts, allows the allogeneic Schwann cells to survive has been investigated. Nerve allografts were inserted by microsurgical techniques into trembler mice treated with 10 mg/kg or 15 mg/kg Cyclosporin A, daily for 12 weeks post-operatively. Electrophysiological recordings were made one week prior to surgery, and at the end of the immunosuppression period, after which the grafts were processed for electron microscopy. All grafts showed signs of rejection and donor Schwann cells had been replaced by host cells. The results suggest that Cyclosporin A in these doses is insufficient to overcome rejection problems or to induce tolerance to donor Schwann cells.

The expression of major histocompatibility complex (MHC) class I and II molecules is important in autoimmune disease processes. Experiments to determine this expression in peripheral nervous tissue cells were carried out utilizing Schwann cells in association with neurons and fibroblasts cultured from explants of human fetal dorsal root ganglia (DRG) at 6 and 15 days in vitro (DIV). Previous studies have examined the expression of these molecules only on isolated Schwann cells. The expression of MHC molecules was determined using immunohistochemistry. When the cultures were incubated with recombinant human interferon-gamma (IFN-gamma), only the Schwann cells expressed class II MHC molecules. This expression increased with time to a maximum by 15 DIV, a stage by which some Schwann cells had ensheathed axonal bundles and others had ensheathed individual axonal lengths. No class II MHC molecules were seen in cultures without IFN-gamma. MHC class I molecules were present on Schwann cells and also on fibroblasts at low levels without IFN-gamma but the level of expression was much increased after IFN-gamma incubation. Maximum expression of class I MHC molecules occurred by 24 h.

Eight patients with chronic inflammatory demyelinating polyneuropathy, five of whom had an associated paraproteinaemia, were treated with cyclosporin in a pilot, uncontrolled study for periods up to three and a half years after failing to respond adequately to corticosteroid and azathioprine therapy and plasmapheresis. Three patients had an excellent response, two with complete remission. In other cases it was possible to reduce the corticosteroid therapy and frequency of plasmapheresis. There were no serious complications of the treatment.

The numbers of helper T and cytotoxic T lymphocytes and macrophages were quantified, and the expression of major histocompatibility complex (MHC) class I and class II molecules was examined in rat peripheral nerve allografts from 1 to 14 days after implantation, using the indirect immunoperoxidase method for light and electron microscopy. Two centimetre segments of peripheral nerve freshly obtained from inbred Dark Agouti strain rats were inserted in a gap created in n. fibularis or n. tibialis of young adult inbred Wistar strain rats, using fascicular nerve repair techniques under general anaesthesia. There was a gradual increase in the number of helper T and cytotoxic/suppressor T cells from day 2 with peak numbers of both types of T cells observed around day 7. The results suggest that the critical time for T cell proliferation is between day 6 and day 7 post-operatively. The number of macrophages increased over 10 days, with peak numbers being observed at day 10 post-operatively. This is in accord with the pattern of rejection observed in allografts of other tissue. Schwann cells were found to express MHC class I and class II molecules by day 2 post-operatively, which is well before there is any substantial T cell and macrophage infiltration. It may be that the donor Schwann cells act as antigen presenting cells, triggering the immune response and finally becoming a target of the rejection process.

HLA typing of 71 patients with chronic inflammatory demyelinating polyneuropathy (CIDP) showed an overall increase in frequencies of HLA-A3, -B7, -DR2 as well as concomitantly decreased frequencies of HLA-44 and DR7. The strongest associations were seen with HLA-DR2, -DR7 and -B44 in CIDP overall, although they did not reach statistical significance.

The expression of MHC class I and II molecules on cultured rat and human Schwann cells (SCs) was studied to determine whether these molecules could be synthesized by SCs in the absence of T cells. Normal rat and human SCs in vitro expressed low levels of class I MHC, but this was markedly increased by incubation with interferon gamma (IFN-gamma). Untreated SCs of rat or human origin did not express detectable class II MHC molecules, but after 48 hours incubation with IFN-gamma 100 U/ml, 20% of rat SCs and 90% of human SCs were class II positive. Immunoelectron microscopy confirmed the surface expression of MHC molecules on SCs and demonstrated class II MHC within endocytotic vesicles. These findings provide further evidence for an immunological role for SCs as antigen presenting cells or as targets for cytotoxic T cells.

The intraneural injection of 25 micrograms/ml of mitomycin C produced a prolonged conduction block of delayed onset within the injected nerve. No change in electrophysiological parameters was seen for 6 days after injection, but thereafter a marked drop in the compound muscle action potential (CMAP) amplitude from stimulation proximal to the site of injection occurred, with recovery not being complete until day 97. CMAP amplitude from stimulation distal to the injection site remained unchanged. The reason for this prolonged period of conduction block was apparent from histological examination of the nerve. Light and electron microscope studies demonstrated Schwann cell death, clearly evident at day 8 and followed by subsequent macrophage removal of myelin and Schwann cell debris. Remyelination was not seen until day 40. Hence for periods of about 30 days naked axons persisted through the area of injection. Schwann cells associated with unmyelinated fibres were relatively unaffected, suggesting that myelinating Schwann cells were vulnerable to this agent by virtue of the metabolic processes associated with their myelin maintenance and renewal. These findings indicate that mitomycin C injected intraneurally provides an excellent model to study the effects of Schwann cell disease.

Serum from rabbits with EAN in the acute phase of the disease has been injected into rat sciatic nerve, and compared to control rabbit serum and serum from patients with demyelinating neuropathy and to normal human control serum. Electrophysiological studies were performed on all rat sciatic nerves so injected, and the nerve was then removed and examined histologically. Control rabbit and human serum and neuropathic human serum, when injected in a 20 microL quantity through a 30 gauge needle, did not produce significant electrophysiological abnormalities. EAN serum, however, produced significant dispersion of the muscle action potential and conduction block. All serum produced some histological evidence of demyelination but that seen with EAN serum was quite profound compared to all other sera. It is concluded that humoral factors are present within animals with EAN which has potent demyelinating potential. We were not able to demonstrate the same effect from patients with demyelinating neuropathy in this test system.

The clinical features, results of nerve conduction studies and sural nerve biopsy findings have been compared in 5 patients with chronic relapsing polyneuropathy in whom plasma exchange was used in treatment. In 2 patients who consistently responded to plasma exchange, the dominant pathological findings was segmental demyelination without prominent onion bulb formation, whereas axonal degeneration was more prominent in the cases which did not respond. It is concluded that in cases of chronic relapsing polyneuritis where the clinical, electrophysiological and histological features suggest primary demyelination, plasma exchange may provide a useful adjunct to therapy.

Four cases of severe peripheral neuropathy directly attributable to nitrofurantoin are reported. The neuropathy was not dose-related and not necessarily associated with abnormal renal function. Recovery was slow, and neither severity nor recovery was related to the total dose of the drug. The pathological changes seen on light microscopy and electron microscopy were those of acute, severe axonal degeneration. It is emphasised that nitrofurantoin is a neurotic drug and should not be prescribed to the elderly not to anyone with impairment of renal function.

P2 protein and 4 synthetic peptides were tested for induction of experimental allergic neuritis (EAN). A peptide comprising the residues 62-78 of the bovine P2 protein sequence has been shown to contain an important neuritogenic determinant. A peptide comprising residues 66-78 produced no clinical symptoms of EAN. These results indicate that some or all of the residues 62 65 (Ile-Ser-Phe-Lys), are necessary for EAN induction.

The possible association of Gm haplotypes with inflammatory neuropathies has been studied in 59 patients with Guillain-Barré syndrome and 55 patients with chronic inflammatory demyelinating polyradiculoneuropathy. The frequency of Gm haplotype 1,2,17;21 (or z,a,x;g) was significantly raised in the patients with Guillain-Barré syndrome. These findings provide further evidence for an association of chromosome 14 genes with inflammatory neuropathies.

A unique case history is presented, of a 42-year-old patient who has suffered three episodes of a demyelinating neuropathy, each of which followed an injection of tetanus toxoid. The clinical features on each occasion were characteristic of acute idiopathic polyneuropathy; a rapid onset of a mainly motor neuropathy with eventual recovery. Nerve conduction studies performed during the second and third episodes demonstrated grossly slowed motor conduction velocities. The sural nerve was biopsied after the third episode, and the features seen on light and electron microscopy included prominent hypertrophic changes, mononuclear cells associated with most "onion bulbs" and macrophage mediated demyelination. Studies of blastogenesis and macrophage migration inhibition, showed T lymphocyte responsiveness to both peripheral nerve myelin and tetanus toxoid. Typing for antigens of the HLA system indicated that the patient was homozygous for HLAB8.

In order to investigate whether Schwann cell or myelin was the principal antigen responsible for nerve graft rejection, fresh nerve grafts and those in which myelin had been previously allowed to degenerate (predegenerate grafts) from both isogeneic BALB/c and allogeneic C57/B1 mice were inserted into trembler BALB/c mice. Schwann cells within nerve allografts from C57/B1 mice were rejected, whether or not the grafts contained myelin. Nerve isografts from normal BALB/c animals produced normally myelinated trembler axons within the grafted segments, and across these segments conduction velocity was restored towards the normal value. It is concluded that Schwann cells, not myelin, constitute the principal antigen within nerve allografts and it is Schwann-cell rejection that limits the successful use of nerve allografts.

Testing hybridoma supernatants for antibodies of interest involves extensive screening, particularly when the immunogen comprises whole cells. The number of different screening procedures is often large and unmanageable and depends on whether one is interested in, for example, cell surface or intracellular binding. This paper describes an initial screening technique using whole tissue homogenate rather than the individual tissue components. The tissue is fixed to the surface of 96-well microtitre plates by microwaves using a conventional microwave oven. This technique provides a rapid and cost-effective means of screening large numbers of monoclonal antibodies.

Experimental allergic neuritis has been induced in 52 guinea pigs by the inoculation of rabbit peripheral nerve in Freund's adjuvant. The majority of the animals developed an acute monophasic illness after a mean interval of 16 days and, if they survived, recovered fully after an average period of 52 days. Two animals displayed a more chronic course and 1 animal relapsed spontaneously after clinical recovery had occurred. Twenty-three animals that recovered were re-inoculated when recovery was complete and in 4 a relapse was induced. In the remainder, no clinical response was observed, even after repeated reinoculations. The ultrastructural appearances in the animals with a monophasic illness were similar to those previously reported. The appearances differed markedly in those animals that were induced to relapse and were similar to those in the animal that relapsed spontaneously. The findings indicated persistent demyelination and remyelination with striking hypertrophic changes (onion bulb neuropathy). The possible reasons for the differences between the two groups are discussed.

Intraspinal injection of mitomycin C into the rat dorsal columns produced extensive demyelination, axonal degeneration and glial cell death. Five weeks post-injection Schwann cell remyelinated fibers were present along the surface of the dorsal columns and around blood vessels within the lesions. Axons near these sites either were enclosed within a Schwann cell but not myelinated or were completely devoid of any cellular ensheathment. Schwann cells were associated only with those blood vessels which no longer retained astroglial end-feet. It is concluded that Schwann cells migrate into spinal cord lesions along such vessels. The marked sub-pial and perivascular distribution of Schwann cell remyelinated fibers may reflect a failure of Schwann cells to disperse quickly elsewhere within the lesion.

In a series of 61 patients with the relapsing variety of chronic inflammatory demyelinating polyneuropathy, there were 16 women of childbearing age, 9 of whom became pregnant. In 4 of these women, the onset of neuropathy occurred in pregnancy and in the other 5 relapses occurred during pregnancy. There was a significant increase in the number of relapses during the year of pregnancy, and a tendency for symptoms to worsen during the third trimester or immediate postpartum period. It is concluded that there is an increased risk of relapse of chronic inflammatory demyelinating polyneuropathy in pregnancy.

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.