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the immunology of SGB

Journal of the Peripheral Nervous System 10:94–112 (2005)
The immunobiology of Guillain-Barre¤ syndromes
Hugh J. Willison
Division of Clinical Neurosciences, Southern General Hospital, Glasgow, Scotland, UK
Abstract This presentation highlights aspects of the immunobiology of the GuillainBarré syndromes (GBS), the world’s leading cause of acute autoimmune neuromuscular
paralysis. Understanding the key pathophysiological pathways of GBS and developing
rational, specific immunotherapies are essential steps towards improving the clinical outcome of this devastating disorder. Much of the research into GBS over the last decade has
focused on the forms mediated by anti-ganglioside antibodies, and we have made substantial progress in our understanding in several related areas. Particular highlights include
(a) the emerging correlations between anti-ganglioside antibodies and specific clinical
phenotypes, notably between anti-GM1/anti-GD1a antibodies and the acute motor axonal
variant and anti-GQ1b/anti-GT1a antibodies and the Miller Fisher syndrome; (b) the identification of molecular mimicry between GBS-associated Campylobacter jejuni oligosaccharides and GM1, GD1a, and GT1a gangliosides as a mechanism for anti-ganglioside antibody
induction; (c) the development of rodent models of GBS with sensory ataxic or motor
phenotypes induced by immunisation with GD1b or GM1 gangliosides, respectively. Our
work has particularly studied the motor nerve terminal as a model site of injury, and
through combined active and passive immunisation paradigms, we have developed murine
neuropathy phenotypes mediated by anti-ganglioside antibodies. This has been achieved
through use of glycosyltransferase and complement regulator knock-out mice, both for
cloning anti-ganglioside antibodies and inducing disease. Through such studies, we have
proven a neuropathogenic role for murine anti-ganglioside antibodies and human GBSassociated antisera and identified several determinants that influence disease expression
including (a) the level of immunological tolerance to microbial glycans that mimic selfgangliosides; (b) the ganglioside density in target tissue; (c) the level of complement
activation and the neuroprotective effects of endogenous complement regulators; and
(d) the role of calcium influx through complement pores in mediating axonal injury. Such
studies provide us with clear information on an antibody-mediated pathogenesis model for
GBS and should lead to rational therapeutic testing of agents that are potentially suitable
for use in humans.
Key words: autoantibodies, Campylobacter jejuni, complement regulator, gangliosides,
glycosyltransferase, Guillain-Barré syndrome, membrane attack complex, neuromuscular
synapse, neuropathy, tolerance
Autoimmune neuropathies are a diverse group of
paralytic syndromes characterised by inflammation in
the peripheral nervous system (PNS), in turn initiated by
a range of quite distinct immunopathological
events. Understanding the immunological mechanisms
Address correspondence to: Prof. Hugh J. Willison, Division of
Clinical Neurosciences, Institute of Neurological Sciences, Southern
General Hospital, Glasgow G51 4TF, Scotland, UK. Tel: þ44-141-2012464; Fax: þ44-141-201-2993; E-mail: [email protected]
2005 Peripheral Nerve Society
Blackwell Publishing
Journal of the Peripheral Nervous System 10:94–112 (2005)
underlying any pathological responses is clearly crucial to
selecting the correct strategies for novel therapeutic interventions, and this is particularly germane to the GuillainBarré syndromes (GBS) where the relative involvement of
T- and B-cell responses is continually debated. In recent
years, great progress has been made in our understanding of this group of disorders. Out of many avenues
explored, one of the most promising has been the discovery and analysis of antibody responses to peripheral
nerve gangliosides and their microbial mimics, the relationships these have to different clinical phenotypes of
GBS, and our increasing insights into their mechanisms of
action. Despite this rapidly advancing progress, considerable gaps in our knowledge persist. The focus of this
lecture is on gangliosides and their corresponding autoantibodies in GBS. I will first provide a brief background to
the field, summarise some of the highlights, identify and
analyse areas of remaining weakness, and then present
some data to support novel therapeutic approaches that
could capitalise on the latest experimental findings.
most other pro-inflammatory insults that lead to neuropathy. The commonest form of GBS arises from segmental demyelination of peripheral nerve (acute
inflammatory demyelinating polyneuropathy [AIDP]),
executed by macrophage-mediated stripping of the myelin sheath (Hafer-Macko et al., 1996b). At least a proportion of this injury appears to be mediated by antibody and
complement deposition on Schwann cell and myelin
membranes, although the putative antigenic target(s) in
AIDP remain elusive, as discussed below. Clinically, this
demyelinating process is widespread, affecting most
myelinated limb, axial and lower cranial motor and sensory nerves, but curiously sparing myelinating axons
innervating extraocular muscles that are so sensitively
affected in Miller Fisher syndrome (MFS). Resting intraneural Schwann cells proliferate and migrate into the
lesion sites to remyelinate denuded axons, producing a
good recovery in most cases. In AIDP, demyelinating
pathology may be extensive throughout the length of
the nerve, especially in proximal nerve roots and the
distal intramuscular nerve segments where the blood–
nerve barrier (BNB) is weak (Olsson, 1968). In agreement, clinical electrophysiological studies indicate that
sites throughout the nerve can be affected but often
point towards proximal (absent or delayed F-wave latencies) or distal (prolonged distal motor latencies) as dominant sites of nerve impairment. It would seem intuitively
likely that the rate of recovery from AIDP should be
independent of the site of demyelination because there
is no evidence that the remyelinating capacity of
Schwann cells varies along the length of the nerve.
Axons are generally unaffected in AIDP, although may
suffer so-called bystander injury, the mechanisms for
which remain unclear and deserve further study.
In contrast to AIDP, the primary target for immune
attack in the GBS variant, acute motor (and sensory)
axonal neuropathy (AMAN, AMSAN) is the axolemmal
membrane (Feasby et al., 1986; McKhann et al., 1993).
Again, this inflammatory process occurs predominantly
either in the nerve roots or distal nerve terminals
(Hafer-Macko et al., 1996a; Ho et al., 1997a;
Kuwabara et al., 2003). Immune attack can lead to
reversible axonal conduction block due to reversible
axonal injury (at best) or complete axonal transaction
(at worst). Wallerian degeneration (Wld) will occur distal to the site if axons are transected; otherwise, myelin is unaffected. Depending on the site of transection
(proximal or distal), axonal recovery may be poor or
good, owing to the distance over which regeneration
is effective (Ho et al., 1997a; 1997b). This is important
clinically because extensive radicular involvement in
AMAN generally leads to a catastrophic, permanent
injury. In contrast, very distal axonal injury would also
induce a severe acute axonal syndrome, but one in
which rapid reinnervation with functional recovery
The Clinical Problem
GBS is the prototypic acute inflammatory disorder
and the foremost cause of post-infectious neuromuscular paralysis worldwide, with a global incidence of
approximately 1.5/105 across all age groups (Hughes
and Rees, 1997; Hahn, 1998). The lifetime likelihood of
any one individual acquiring the disease is thus approximately 1 : 1000. Onset is rapid, and approximately 20%
of cases lead to total paralysis, requiring prolonged
intensive therapy with mechanical ventilation. The therapeutic window for GBS is short, and the current optimal treatment with whole plasma exchange or
intravenous immunoglobulin (Ig) therapy lacks immunological specificity and only halves the severity of the
disease (Visser et al., 1999; 2004; Raphael et al., 2001;
Hughes et al., 2004a; 2004b). The patients left severely
disabled (approximately 12% survivors unable to walk
after 1 year) or dead (UK mortality of 5–10%) represent
a major social and economic burden (Buzby et al., 1997).
Thus, there is an incentive to understand GBS pathogenesis as a prerequisite to developing and instituting
effective, contemporary immunotherapies.
Clinical and Pathological Patterns of GBS
Despite the all-embracing eponym, GBS’s clinical
pathophysiology is long recognised as being highly complex (Hartung et al., 1995a; 1995b). GBS is an acute
phase illness occurring 10–14 days after trivial infections,
comes and goes rapidly (within 4 weeks), and leaves
variable residual injury. The acute, monophasic nature
of GBS provides crucial clues to the immunopathological
background and quite clearly distinguishes GBS from
Journal of the Peripheral Nervous System 10:94–112 (2005)
mitigate against the major structural proteins of myelin
being dominant AIDP antigens. A chronic ataxic neuropathy has also been reported that may be associated
with relapsing ophthalmoplegia in some cases; such
patients often have anti-ganglioside antibodies, including anti-GQ1b, which are persistently present, usually
occurring as IgM paraproteins (Willison et al., 2001).
could readily occur (Ho et al., 1997a; Kuwabara et al.,
Formes Frustes of GBS Also Exist as
Regional Variants
The regional variants of GBS only paralyse specific
areas of the body, such as the eyes or face, or the
afferent sensory and autonomic systems (Ropper,
1994). The most widely studied of these variants is the
MFS (Fisher, 1956; Willison and O’Hanlon, 1999). Our
understanding of MFS was revolutionised following
Chiba and Kusunoki’s discovery of the anti-GQ1b antibody marker (Chiba et al., 1992; 1993). Since the syndrome was first described in 1956 as the discrete clinical
triad of ophthalmoplegia, ataxia, and areflexia, anti-GQ1b
antibody testing has allowed MFS to evolve nosologically and now encompasses closely related formes
frustes, mainly characterised by acute cranial motor neuropathies with ataxia – the anti-GQ1b antibody syndromes (Odaka et al., 2001; Paparounas, 2004). In the
Bickerstaff’s encephalitis, MFS-like features occur in
conjunction with brain stem involvement, comprising
pyramidal tract signs and impaired consciousness, and
two thirds of cases are anti-GQ1b antibody positive
(Bickerstaff and Cloake, 1951; Odaka et al., 2003). The
close relationship between GBS and MFS is considered
because it should direct our search towards common
underlying immunopathological mechanisms. Thus,
some MFS cases merge into confluent GBS with
respiratory and limb involvement, and similarly, some
GBS cases also evolve to develop an MFS pattern of
clinical involvement – in these overlapping cases, antiGQ1b antibodies are generally detected. MFS variants
include solitary ophthalmoplegia or ataxia and oropharyngeal weakness without ophthalmoplegia (O’Leary
et al., 1996). Viewed in its broadest contemporary
sense, MFS could be considered as a PNS/CNS overlap
syndrome with extremely variable degrees of involvement of particular central or peripheral anatomical sites
in individual cases, with all permutations being highly
associated with anti-GQ1b and anti-GT1a antibodies
(O’Leary et al., 1996; Odaka et al., 2001).
The selective affliction of cranial and in particular
extraocular nerves in the anti-GQ1b antibody syndromes is believed to be due to the enrichment of
the target antigen(s) in affected sites (Chiba et al.,
1997). However, there are clearly additional levels of
complexity influencing the clinical phenotype that
remain undiscovered. What is notable by its absence
is involvement of extraocular motor nerves in AIDP,
arguing that the AIDP antigen(s) may analogously be
relatively enriched in limb and axial myelin (in comparison with extraocular motor nerve myelin) as opposed
to being a generic myelin antigen(s). This might
Anti-Nerve Antibodies in GBS: Lessons
From Rodent Models
Great progress has been made in correlating clinical
phenotypes with serological profiling of anti-nerve antibodies, covering a wide spectrum of peripheral nerve antigens. The myelin protein-specific T and B cell-mediated
rodent model of GBS (experimental allergic neuritis [EAN])
was described 50 years ago and has yielded many important experimental insights into peripheral nerve inflammation (Spies et al., 1995; Rostami, 1997; Gabriel et al., 1998;
Taylor and Pollard, 2003). However, translational studies
identifying equivalent immune responses in human neuropathy cases have been more modest (Gabriel et al., 2000;
Ritz et al., 2000; Yan et al., 2000; Favereaux et al., 2003;
Latov and Renaud, 2004). Whether further research will
overcome this remains to be seen.
In contrast, the progress in identifying myelin and
axonal glycolipids as antigens has been somewhat
more forthcoming. Interestly that ganglioside-/glycolipidinduced rabbit EAN was also first described several
decades ago (Nagai et al., 1976; Saida et al., 1979),
but in contrast to myelin protein-induced EAN, was
then virtually neglected for approximately 20 years,
and has now been revived with compelling data that
reinforce many recent clinical findings. Thus, a series
of recent rabbit immunisation studies have led to the
generation of models of anti-GD1b antibody-associated
ataxic neuropathy and anti-GM1 antibody-associated
motor axonal neuropathy that mimic many of the clinical and pathological features of the human syndromes
(Kusunoki et al., 1996; Yuki et al., 2001; 2004).
These studies have provided some of the most
compelling evidence that anti-ganglioside antibodies
and their effector pathways can induce clinically relevant phenotypes. In this respect, ganglioside-induced
EAN has come full circle. The return of researchers,
principally in Japan, to these early rabbit studies was
driven in large part by the clinical identification of antiganglioside antibodies in GBS cases, starting in 1988
(Ilyas et al., 1988) and escalating in scope ever since. A
wealth of clinical serological associations have now been
described and the topic reviewed regularly (Yuki, 2001;
Willison and Yuki, 2002). In summary, in human disease,
anti-GM1, anti-GD1a, anti-GM1b, and anti-GalNAcGD1a
antibodies are highly associated with AMAN (Ogawara
et al., 2000) and anti-GQ1b, anti-GT1a, anti-GD3, and
Journal of the Peripheral Nervous System 10:94–112 (2005)
sulfatides that also have microbial glycan mimics
(Yuki, 2001; Willison and Yuki, 2002).
anti-GD1b with MFS and chronic ataxic neuropathy
(Chiba et al., 1993; Willison et al., 2001). Anti-GM1 IgG/
IgM antibodies are also associated with AIDP and
chronic demyelinating clinical phenotypes, the latter
with or without concomitant axonopathy, as seen in
multifocal motor neuropathy (Pestronk and Choksi,
1997). However, considerable debate still remains as to
the relative extent of demyelinating and axonal pathology that can be associated with anti-GM1 antibody syndromes. An exciting new finding has suggested that
gangliosides assembled in complexes (in this case
GM1 and GD1a) (Kaida et al., 2004) might provide higher
avidity targets for GBS-associated autoantibodies than
single ganglioside species. Although it has long been
known that accessory lipids play an important role in
enhancing or attenuating ganglioside–antibody interactions, this provocative finding greatly raises the complexity of examining sera for the new autoantibody
specificities, including the elusive AIDP antigen(s).
Immunological Tolerance Exists to
Self-Ganglioside Structures
One of the curiosities of GBS is that such a small
proportion of infections or vaccinations triggers the
illness. Thus, 99% of humans infected with ganglioside-mimicking strains of C. jejuni neither develop antiLOS/ganglioside antibodies nor GBS (Nachamkin,
2001). The immunological factors that regulate this
unresponsiveness to challenge with microbial mimics
of self-glycan structures are poorly understood, but
it seems likely that B-cell tolerance is an important
component. Anti-LOS/ganglioside antibodies exist
within the natural antibody repertoire, acting as
innate defence against bacteria. Being carbohydrates,
gangliosides elicit T cell-independent (TI) humoral
responses (Martin et al., 2001; Zubler, 2001) and cannot be presented by major histocompatibility complex
molecules (Ishioka et al., 1993) (except via CD1 presentation [Brigl and Brenner, 2004; Watts, 2004] ).
Anti-ganglioside antibodies exist as low-affinity IgM
isotypes in normal subjects (Willison et al., 1993;
Mizutamari et al., 1994; Casali and Schettino, 1996).
To prevent autoimmune reactions, their level and affinity are controlled by tolerance (Cornall et al., 1995;
Fagarasan and Honjo, 2000). In GBS, the appearance
of high titre anti-ganglioside antibodies is a clear failure
of tolerance. B-cell tolerance to TI ganglioside antigens
is poorly understood and remains a major research
goal in the GBS field. Aspects are analogous to organ
transplantation paradigms involving Gal(a1–3)Gal antigens as studied in a1–3galactosyltransferase knockout (KO) mice (Kawahara et al., 2003; Galili, 2004)
and in the ABO blood group system (Fan et al., 2004;
Fehr and Sykes, 2004).
We and others anticipated that the expression of
gangliosides in tissues outside the nervous system
that can be sensed by newly developing and pre-existing B cells (bone marrow and spleen, respectively)
would be an important regulator of tolerance, as suggested for anti-Gal(a1–3)Gal (Yang et al., 1998). Thus,
we showed that mice lacking complex gangliosides in
any tissue (i.e., the GalNAcT KO mice that only
express GM3 and GD3, see Fig. 1) develop exaggerated humoral responses to gangliosides compared
with wild-type (WT) controls when challenged with
C. jejuni LOS (Bowes et al., 2002) or gangliosides
(Lunn et al., 2000). An example of the differential antibody responses to GD1a ganglioside and GD1a-bearing
C. jejuni LOS in GalNAcT WT and KO mice that clearly
illustrates this principle is shown in Figure 2.
Gangliosides and Structural Mimics on
Microbial Glycans
One highly fruitful area has been the discovery of a
range of ganglioside and glycolipid mimics on microbial
glycans (Yuki et al., 1993; Yuki, 2001). There are
approximately 50 structurally distinct gangliosides
synthesised through step-wise addition of monosaccharides by Golgi glycosyltransferases in complex
developmental, spatial, and cell-specific patterns
(Kolter et al., 2002). Gangliosides are enriched in neural
tissues and primarily localised to raft domains of the
extracellular leaflet of plasma membranes, especially
at synapses, where they are available for antiganglioside antibody binding (Ledeen, 1978; Ledeen and
Yu, 1982; Ledeen et al., 1998; Ogawa-Goto and Abe,
1998). A simplified scheme of the major ganglioside
structures is shown in Figure 1. The carbohydrate moieties of gangliosides are structural mimics of microbial
glycans, including the lipo-oligosaccharides (LOS) of
Campylobacter jejuni (Aspinall et al., 1994; Yuki et al.,
1997; Sheikh et al., 1998; Prendergast and Moran,
2000; Moran et al., 2002) and Haemophilus influenzae
(Mori et al., 1999; Ju et al., 2004). Evidence from
human and animal studies indicates a key role for this
molecular mimicry in GBS pathogenesis (Goodyear
et al., 1999; Bowes et al., 2002; Yuki et al., 2004). In
this model, well documented for GM1, GD1a, and
GQ1b, the acute phase anti-LOS/ganglioside complementfixing IgG antibodies that arise eradicate infections but
also bind to peripheral nerve gangliosides where they
induce autoimmune injury. Potential pathogenic role(s)
exist for other known and unknown glycolipids
enriched in Schwann cell, myelin, and axonal membranes, such as galactocerebroside, LM1, and
A Ugcg–/–
Journal of the Peripheral Nervous System 10:94–112 (2005)
A simplified scheme of the ganglioside biosynthetic pathway
0 series
a series
b series
Candidate oligosaccharide fragments for inhibition/immunoadsorption studies
Examples of Campylobacter jejuni LOS stuctures
HS:19(GM1+, GD1a+) and HS:4
Lipid A
Lipid A
HS:19(GM1+, GT1a+)
Lipid A
Lipid A
Lipid A
Cer Ceramide
Figure 1. A schematic representation of the key structures and enzymes in ganglioside biosynthesis, relevant glycan
fragments, and core structures identified in Campylobacter jejuni lipo-oligosaccharides. Note that GalNAc transferase
(GalNAcT) and GD3 synthase (GD3s) deficiency result in the loss of all complex and b-series gangliosides, respectively.
Isolating and Characterising Murine
Monoclonal Anti-Ganglioside Antibodies
immunisation protocols using ganglioside–protein
conjugates and LOS/ganglioside liposome-encapsulated
proteins to provide the necessary T cell-dependent
(TD) environment required to produce the magnitude
of immune responses seen in Figure 2. Using these
methods, we and others have generated long-lived IgG
memory responses to gangliosides and to LOS in glycosyltransferase KO mice. Using such an approach,
we have cloned approximately 50 IgG/IgM monoclonal
antibodies specific for discrete ganglioside epitopes for
use in a wide range of pathogenesis and therapeutic
studies (Boffey et al., 2004; Willison et al., 2004).
An offshoot of these experiments aimed at
bypassing tolerance to microbial glycans has been
the creation of high-affinity IgG responses to gangliosides that are suitable for cloning top quality anti-ganglioside antibodies – a long-awaited goal for these
poorly immunogenic structures. In addition to overcoming any tolerogenic factors, to circumvent any TI
restriction on affinity maturation and class switching
(including that which might occur in glycosyltransferase
KO mice), we have developed hapten-carrier
Journal of the Peripheral Nervous System 10:94–112 (2005)
resonance) indicate that affinity maturation for most
AG monoclonal antibodies is modest, even amongst
class-switched monoclonal antibodies isolated from
glycosyltransferase KO mice (Townson, unpublished
data). Collectively, these murine data indicate that
diverse antibody specificities encoded by restricted
sets of VH/VL genes reside within the natural antibody
repertoire and can be expanded by bacterial LOS once
released from tolerance. This is not necessarily associated with affinity maturation; nevertheless, such antibodies can readily injure the PNS, as described below.
The observations we have made with murine antibodies has shifted our predictions about the likely shape
of the human anti-ganglioside antibody repertoire in
GBS, which is not well understood because few have
been cloned to date apart from long-lived IgM antibodies (Paterson et al., 1995). It is known that the antibody
response in GBS has class-switched from IgM to the
TD complement-fixing IgG1 and IgG3 isotypes (Willison
and Veitch, 1994). This would usually co-occur with
affinity maturation of a range of clones within the
B-cell repertoire. However, we now suspect that the
repertoire may be considerably more clonally restricted
and unmutated in GBS than previously thought and are
currently investigating this area. In support of the relatively low affinity for GBS-associated antibodies are our
findings that (a) human IgG anti-GQ1b antibodies can be
readily displaced from antigen by polyclonal human IgG
(IVIg therapy) (Jacobs et al., 2003) and (b) they slowly
elute off immuno-affinity columns in the presence of
physiological strength buffers (Willison et al., 2004).
This has important implications for several therapeutic
strategies aimed at inhibition of antibody–glycan interactions or selective ablation of ganglioside-specific
B-cell pools, as outlined in Figure 3.
Optical density
Immunisation number
Figure 2. Anti-ganglioside IgG antibody responses in
GalNAc transferase (GalNAcT)þ/þ and GalNAcT–/– mice following intraperitoneal immunisation with HS:4 lipo-oligosaccharides (bearing a GD1a epitope, left-hand panels) or GD1a/
ovalbumin liposomes (right-hand panels). Mice were immunised at 2-weekly intervals and bled 4 days after each immunisation. Elevated anti-GD1a antibody titres are evident in
GalNAcT–/– mice (deficient in GD1a) by the second or third
immunisation, compared with non-responding GalNAcTþ/þ
mice (*p < 0.005). Modified from Bowes et al. (2002).
These antibodies have been powerful tools in enhancing our understanding of pathogenic pathways that
model the human disorders.
One area of particular interest is in understanding
structure–specificity relationships amongst antibodies
and their binding partner glycans. Thus, Ig variable (V)
region sequencing, affinity, and glycan-binding studies
on the above IgG/IgM mouse monoclonal antibodies
have allowed us to investigate whether (a) specificity is
dictated by particular V-gene usage and (b) class
switching from IgM to IgG is associated with affinity
maturation. Interestly that the minor alteration in specificity from terminal disialosyl residues (on GQ1b,
GT1a, and GD3) to internal disialosyl residues (on
GD1b and GT1b) is mutually exclusively associated
with a change from murine VH7183.3b to VH10.2b
gene segment usage (Boffey et al., 2004; Boffey,
unpublished data). V-gene mutation rates and affinity
measurements (using Biacore surface plasmon
The Sites and Mechanisms by Which AntiGanglioside Antibodies Paralyse the PNS
Anti-ganglioside antibodies could potentially bind
any ganglioside-containing membranes, provided that
they can gain access and binding is not subject to steric
inhibition locally in the membrane. One site for antibody
action we discovered and have worked on extensively
is the ganglioside-rich, pre-synaptic component of the
neuromuscular junction (NMJ), lying outside the BNB
where its membranes are readily accessible to circulating antibodies. Other important proximal axonal and glial
sites of injury exist, especially exposed axolemma at
nodes of Ranvier and paranodal myelin, as has been
well demonstrated in a wide range of human studies
described above and in animal studies (Kusunoki et al.,
1996; Yuki et al., 2001; Sheikh et al., 2004).
One reason why our studies initially focused on
the NMJ was because of the longheld appreciation of
Journal of the Peripheral Nervous System 10:94–112 (2005)
A Mechanistic Pathway for NerveTerminal
Axonal Injury Culminating in Synaptic
Immunoadsorption columns
We first demonstrated using in vitro mouse hemidiaphragm preparations that anti-GQ1b antibodies associated with MFS bind the motor nerve terminal where
they locally activate complement (Roberts et al., 1994;
Plomp et al., 1999; Halstead et al., 2004). A schematic
diagram of the pathological processes occurring in this
model that summarises an extensive series of experiments is shown in Figure 4. Following antibody binding
with local complement fixation, an uncontrolled influx of
calcium into the nerve terminal through membrane
attack complex (MAC) complement pores then provokes
spontaneous exocytosis, accompanied by calpainmediated structural degradation of the terminal axonal
cytoskeleton and calcium-mediated mitochondrial injury,
with resultant paralysis (O’Hanlon et al., 2001; 2003).
MAC formation is essential because C6-deficient conditions abolish the effect (Halstead et al., 2004). Features
of this lesion are similar to those induced by the poreforming toxin, a-latrotoxin (O’Hanlon et al., 2002). We
have used the term ‘synaptic necrosis’ to describe these
events in distinction from other forms of synapse elimination including synaptosis (Gillingwater and
Ribchester, 2003). To illustrate this process, Figure 5
shows synaptic necrosis occurring at nerve terminals in
Thy1-CFP/YFP transgenic mice that express fluorescent
protein in the cytosolic compartment of the whole motor
axon including the nerve terminal (collaboration, R.
Ribchester) and Figure 6 shows the electrophysiological
events occurring concomitantly with this structural disintegration (collaboration, J. Plomp). There is evidence
that anti-GM1, anti-GD1a, and anti-GalNAcGD1a antibodies may also act in part at the NMJ (Roberts et al., 1995;
Taguchi et al., 2004a; Goodfellow et al., 2005), as
described below and seen in Figures 6 and 7.
The extent to which anti-ganglioside antibodymediated nerve terminal degeneration extends proximally up the axon remains uncertain and may be influenced by the ganglioside specificity of the antiganglioside antibodies and the integrity of the BNB
and local regulators of complement activation. The
pathophysiological pathways underlying synaptic and
axonal degeneration may be distinct, as suggested by
studies in the slow Wld (Wlds) mutant mouse (Mack
et al., 2001; Gillingwater and Ribchester, 2003). When
applying anti-GQ1b antibodies to this MFS model, the
nerve terminal of Wlds mice is not protected from
MAC-mediated injury, undergoing degeneration to the
same extent as seen in WT mice (Willison et al.,
unpublished data), however, any influence of Wlds in
protecting the more proximal axon from injury is
GM1-sepharose column
From patient
To patient
Soluble oligosaccharide
fragments as inhibitors
Complement components
and regulators
C3 convertase
C5 convertase
Figure 3. A schematic diagram of potential therapeutic targets and strategies based on inhibition or removal of antiganglioside antibodies, inhibition of steps in complement
activation, or enhancement of complement regulation.
the clinical resemblance between MFS and botulism
(Marvaud et al., 2002). Botulinum toxins bind the nerve
terminal in part by using gangliosides as ectoacceptors
(Montecucco et al., 1988; Kitamura et al., 1999;
Bullens et al., 2002), prior to their cytosolic uptake
and proteolytic action on proteins of the release
machinery (Schiavo et al., 2000). It thus seemed logical
that anti-ganglioside antibodies might also act at the
NMJ to induce paralysis, albeit through a different
mechanism. Emerging clinical electrophysiological evidence suggests that nerve terminal dysfunction occurs
in both MFS and GBS (Uncini and Lugaresi, 1999;
Wirguin et al., 2002; Kuwabara et al., 2003; Spaans
et al., 2003; Lo et al., 2004). However, it is also important to recognise the immunohistological observations
of Chiba and colleagues that have clearly demonstrated
anti-GQ1b antibodies binding to extra-ocular nerve
nodes of Ranvier and it may well be that multiple neural
sites for antibody attack exist that may differ both
between syndromes and individuals (Chiba et al., 1993).
Journal of the Peripheral Nervous System 10:94–112 (2005)
Complement classical
pathway activation
Lipid Raft
mitochondrial dysfunction
cytoskeleton disintegration
Figure 4. A schematic diagram of the events occurring at nerve terminals in experimental nerve-muscle preparations exposed to
anti-ganglioside antibodies in the presence of complement. Exocytosis is normally initiated by highly regulated calcium entry through
voltage-gated calcium channels that activate the adjacent SNARE complex and initiate synaptic vesicle fusion with the pre-synaptic
membrane. When membrane attack complex (MAC) pores are deposited in the pre-synaptic membrane, unregulated calcium entry
triggers massive, uncontrolled exocytosis and calcium-/calpain-mediated intra-terminal injury, including cytoskeletal degradation and
mitochondrial death. The pore-forming toxin, a-latrotoxin, is believed to act in part through a similar mechanism, allowing unregulated
calcium influx with electrophysiological and morphological sequelae similar to those resulting from MAC pores.
Anti-Disialylated Ganglioside Antibodies
Target the Perisynaptic Schwann Cell
to which perisynaptic Schwann cell (pSC) injury might
contribute to distal motor axonal degeneration.
Similarly to the axonal element of the nerve terminal,
the pSC lies outside the BNB where it is fully exposed
An interesting neuropathogenic mechanism that
has not been explored in human disease is the extent
Figure 5. Neuromuscular junctions in triangularis sternae muscle preparations from B6.Cg-Tg(Thy1-CFP) green fluorescent mice
were exposed in vitro to anti-GQ1b monoclonal antibody and the nuclear marker, ethidium dimer (EthD-1). Images were collected
before (A) and 7 min after (B) the addition of human serum as a source of complement. (A) Normally appearing green fluorescence is
visible in axon terminals overlying the post-synaptic membrane (stained for bungarotoxin, blue) and EthD-1 is excluded (and therefore
not seen in this image) from perisynaptic Schwann cell (pSC) nuclei, as normal. (B) Green fluorescence has disappeared through
leakage from the axon terminal undergoing acute synaptic necrosis. Concomitantly, EthD-1, which is normally excluded from the
intracellular compartment, has been taken up into pSC nuclei (that now appear red) because of pSC plasma membrane injury.
Journal of the Peripheral Nervous System 10:94–112 (2005)
et al., 1998; Auld and Robitaille, 2003; Love et al.,
2003; Reddy et al., 2003; Halstead et al., 2004; Liu
et al., 2004). The selective ablation of pSCs at mammalian NMJs has not been previously achieved and
their role in human disease not considered. We have
recently been able to segregate injury to these two
compartments. Interestingly, pSC ablation induced no
acute electrophysiological or morphological changes to
the underlying nerve terminal, suggesting that at mammalian NMJs, acute pSC injury or ablation has no major
deleterious influence on synapse function. However, it
is expected that the absence of pSCs may well have a
deleterious effect on the longer-term integrity of the
underlying synapse, and this area deserves further
attention. Information on ganglioside distribution in different membranes and cell types at the human NMJ is
sparse, although this is known to be a ganglioside- and
glycan-rich area (Martin, 2003). One might expect to
see variations in ganglioside distribution that correlate
with clinically affected sites (e.g., cranial nerves, polysialylated gangliosides; limb nerves, ‘a series’ gangliosides) (Ogawa-Goto et al., 1992; Chiba et al., 1997;
Ogawa-Goto and Abe, 1998; Gong et al., 2002), and
this is an area that deserves further study.
1 mv
100 ms
EPP amplitude (mV)
t = 10
t = 11
Time (min)
t = 12
10 mV
t = 13
20 ms
Figure 6. Microelectrode recordings from GD3s–/– and wildtype (WT) mouse ex vivo hemidiaphragm preparations exposed
to anti-GD1a antibodies raised in GalNAcT–/– mice immunised
with Campylobacter jejuni lipo-oligosaccharides. (A) Acute exposure of nerve terminals to anti-GD1a antibody causes a massive
increase in miniature endplate potential (MEPP) frequency at the
GD3s–/– neuromuscular junction (NMJs), with no effect at WT
NMJs. The anti-GD1a antibody effect is entirely dependent on
the presence of a source of complement. (B) An example of
neurotransmission failure at GD3s–/– NMJ induced by anti-GD1a
antibody plus complement. The phrenic nerve of a GD3s–/–
diaphragm nerve-muscle preparation was stimulated once
every 30 s over a 13-min monitoring period, in the presence of
m-conotoxin-GIIIB to prevent muscle action potentials. Endplate
potentials (EPPs) were recorded at an NMJ where MEPP frequency was very high (>100/s, visible at the baseline of traces).
EPPs were normalised to 75 mV and superimposed. The EPP
decreased with time after complement addition and became
blocked. This did not occur at WT or GalNAcT–/– nerve terminals
and did not occur without the anti-GD1a monoclonal antibody
(experiments conducted by J. Plomp, modified from Goodfellow
et al., 2005).
The Role of Complement Regulators and
Therapeutic Inhibitors in Attenuating Nerve
An important body of evidence has proven that antiganglioside antibodies exert their paralytic effects
directly (Buchwald et al., 1998; 2001; Ortiz et al., 2001;
Taguchi et al., 2004a; 2004b). Nevertheless, tissuebound antibody of the appropriate class should automatically fix complement that would therefore exacerbate
injury over and above any direct actions of antibody
(Koski et al., 1987). It is for this reason that many of our
recent studies have focused on complement-dependent
injury and begun to investigate complement inhibitors
and regulators as therapeutic targets, as outlined in
Figure 3. Complement activation is regulated by an
equally complex inhibitory process, mediated by human
and mouse decay-accelerating factor (DAF), CD59, complement receptor 1 (CR1), and mouse CR1-related gene
y (Crry) (Morgan and Harris, 2003; Turnberg and Botto,
2003; Mizuno and Morgan, 2004). CD59 inhibits the
formation of MAC and DAF accelerates the decay of
C3/C5 convertases (Lukacik et al., 2004; Mizuno and
Morgan, 2004; Harris et al., 2005). Thus, we recently
discovered that CD59-deficient mice are excessively
vulnerable to anti-ganglioside antibody-dependent complement-mediated injury (Halstead et al., 2004). An
example of this effect is shown in Figure 9. These findings agree with data from experimental myasthenia
to the extracellular fluid environment. Using antiganglioside antibodies with different specificities for
GQ1b, GT1a, and GD3, and for GM1 and GD1a, we have
shown that anti-ganglioside antibodies can (a) destroy
the nerve terminal (i.e., synaptic necrosis), (b) kill the
pSC that envelops the pre-synaptic region, or (c)
destroy both nerve terminal and pSC (Halstead et al.,
2004; Halstead et al., 2005). Model schemes of this
injury are shown in Figure 7, and an electron micrograph of selective pSC damage induced by an antidisialosyl antibody is shown in Figure 8. pSCs support
the underlying motor nerve terminal, both in the steady
state and during development and regeneration (Kong
Journal of the Peripheral Nervous System 10:94–112 (2005)
Normal NMJ
Injured NT; reactive pSC
Schwann cell
Nerve terminal
Muscle surface
Injured NT and pSC
Injured pSC; normal NT
MAC pores
Figure 7. (A) Schematic representation of the normal neuromuscular junction (NMJ) and (B–D) different patterns of NMJ injury
occurring on exposure to complement-fixing anti-ganglioside antibodies. At NMJs in which the nerve terminal (NT) alone is injured
(e.g., by anti-GD1a antibodies), the terminal axon disintegrates and the perisynaptic Schwann cell (pSC) becomes reactive,
extending processes that interdigitate between the axonal fragments and envelope the remaining terminal with wraps of
Schwann cell membranes. If the pSC is concomitantly injured by complement deposits along with the NT (e.g., by anti-disialosyl
antibodies), the pSC reactive response does not take place, and the pSC undergoes rapid necrotic disintegration. Antibodies that
induce acute pSC death alone appear to spare the nerve terminal in the short term, both morphologically and functionally.
immunised mice both ex vivo and in vivo, as shown in
Figure 10 (Halstead et al., unpublished data). The therapeutic window for APT070 intervention in passive and
active immunisation models of GBS remains unknown,
but clearly, it is a possible intervention in human neuropathies in which complement deposits are implicated.
gravis (Lin et al., 2002; Kaminski et al., 2004) and experimental allergic encephalomyelitis (Mead et al., 2004).
It is very clear that complement activation with MAC
formation drives neural membrane injury in anti-GQ1btreated mouse tissue (Halstead et al., 2004). It is also
well established that MAC is present in human GBS
biopsy material (Lu et al., 2000; Putzu et al., 2000;
Wanschitz et al., 2003). It would thus appear likely that
blocking MAC formation locally should prevent MACdependent tissue injury, even if anti-ganglioside antibody
is deposited in the membrane. One therapy we have
used to investigate this is the complement inhibitor,
APT070 (collaboration, R. Smith, Inflazyme). APT070
contains the C3/C5 convertase-inhibiting region of CR1
and a membrane-localising peptide that allows it to inhibit complement accumulation (Linton et al., 2000; Smith
and Smith, 2001; Pratt et al., 2003). Using APT070, we
can completely abrogate MAC formation and acute tissue injury by pre-treatment of anti-ganglioside antibody-
The Influence of Ganglioside Density on
Nerve Vulnerability to Anti-Ganglioside
Antibody Attack
One of the most interesting enigmas surrounding
GBS is the regional pattern of clinical involvement and
the way that this links in with anti-ganglioside antibody
specificities. Clearly, this regional involvement can
potentially be accounted for at many different levels.
The most striking example of this is MFS, in which
anti-GQ1b and anti-GT1a antibodies appear to target
the oculomotor and bulbar nerves because GQ1b and
Journal of the Peripheral Nervous System 10:94–112 (2005)
Figure 8. Mouse monoclonal anti-disialosyl antibodies segregate into groups according to whether they injure the nerve
terminal, the perisynaptic Schwann cell (pSC), or both, following passive exposure of mouse neuromuscular junctions to
antibody in the presence of complement. In this low-magnification electron micrograph, an antibody that kills the pSC and
spares the axon is shown. A motor axon is wrapped by the last myelinating Schwann cell just proximally to the nerve terminals
(NTs) that form synaptic contact with a muscle fibre. The NTs have a normal morphology, with electron-dense mitochondria
and tightly packed synaptic vesicles. Two pSCs sitting on either side of the terminal axon appear severely damaged with
swollen and electron lucent cytoplasm, damaged organelles, nuclear membrane blebbing, and perinuclear bodies (arrowheads), all indicative of necrotic cell death. Two myonuclei (MN) beneath the post-synaptic membrane projecting into this plane
of section are of normal appearance. By immunofluorescence, these pSCs would be laden with anti-disialosyl antibody and
complement products. Scale bar ¼ 5 mm (Halstead et al., unpublished data).
GalNAcT–/– and anti-GD1a antibody into GD3s–/– mice)
that this enhancement of ganglioside levels confers sensitivity to development of disease compared with the
relatively insensitive WT mice that express ‘normal’
levels of ganglioside (Bullens et al., 2002; Goodfellow
et al., 2005). This is particularly well illustrated in the
GD3s–/– mouse exposed to anti-GD1a antibody, as
shown pictorially in Figure 11. What is now required is
an extensive regional evaluation of the human PNS to
map ganglioside density in key sites, including axonal,
glial, and nerve terminal membranes, most easily conducted by quantitative immunofluorescence in order to
preserve gross anatomical information that is largely lost
when using preparative biochemical techniques.
GT1a are enriched in those sites. By corollary, because
AMAN or AIDP occurring in the absence of anti-GQ1b
antibody spares the oculomotor nerves, the relevant
antigens should be missing or at a low enough density
to escape targeting by antibody. In considering this,
the term density is solely intended here to refer to the
total amount of membrane ganglioside, independent of
any effect of raft compartmentalisation that might concentrate antigen in discrete regions (Herreros et al.,
2001; McKerracher, 2002; Guan, 2004).
In this area, GalNAcT–/– and GD3s–/– mice have told
us a lot about the extent to which ganglioside density
in neural membranes influences the degree of antiganglioside antibody-mediated neural injury. Firstly, it is
necessary to recall that glycosyltransferase KO mice
develop precursor substrate build-up above the enzyme
block and direct excess gangliosides down other available routes in the biosynthetic pathway (Sandhoff and
Kolter, 2003). Thus, GalNAcT–/– mice contain only GM3
and GD3, but in excess amounts, whereas GD3s–/– mice
lack all ‘b series’ gangliosides and overexpress the ‘a
series’ products, GM1 and GD1a (Kawai et al., 2001;
Okada et al., 2002). We have discovered in two models
(passive immunisation of anti-GD3 antibody into
Treatment of GBS by Removal or
Neutralisation of Anti-Ganglioside
As stated earlier, GBS is unlikely to ever be preventable; thus, optimising acute therapy is paramount.
We have considered a number of therapeutic interventions that would be suitable for use at clinical presentation in what we believe to be antibody-mediated forms
Journal of the Peripheral Nervous System 10:94–112 (2005)
CD59+/+, anti-GQ1b antibody
Signal (% BTx area)
CD59+/+, PBS
CD59–/–, anti-GQ1b antibody
CD59–/–, PBS
Figure 9. Complement regulator intact (CD59þ/þ) and deficient (CD59–/–) mice were passively immunised for 20 h with anti-GQ1b
immunoglobulin (Ig)M monoclonal antibody plus human serum as a heterologous source of complement. Diaphragm neuromuscular
junctions (NMJs) were analysed for deposits of anti-GQ1b IgM and membrane attack complex (MAC) and for neurofilament (NF)
degradation as an index of neuronal injury. Whereas IgM deposits were equal, MAC deposits were increased nearly twofold in CD59–/–
mice compared with CD59þ/þ wild-type mice (p < 0.001). NF signals over the NMJ were greatly reduced in CD59–/– compared with
CD59þ/þ mice, in relation to their phosphate-buffered saline (PBS)-treated controls (p < 0.001). (A) Deposits of MAC over bungarotoxin
(BTx)-labelled NMJs in CD59–/– mice. (B) Normally appearing synaptic and pre-synaptic NF as a measure of axonal integrity in a CD59–/–
mouse exposed to PBS, compared with the CD59–/– mouse passively immunised with anti-GQ1b antibody plus complement, in which
the nerve terminal NF signal is lost (C). Scale bar ¼ 20 mm. Modified from Halstead et al. (2004).
(Andersen et al., 2004; Willison et al., 2004). Some of
these structures are shown in Figure 1. By using such
approaches, we have established that all mouse antiGQ1b monoclonal antibodies and >50% human MFS
sera bind NeuNAc (a2–8)NeuNAc(a2–3)Gal- (disialylgalactose, DSG), the terminal trisaccharide of GQ1b,
GT1a, and GD3. Anti-GM1 monoclonal antibodies
either require Gal(b1–3)GalNAc or whole GM1 pentasaccharide (100 nM GM1 for >90% inhibition). By
using DSG- or GM1-sepharose immunoabsorption columns, we can readily deplete anti-GQ1b and anti-GM1
antibody from MFS and GBS sera.
In a collaborative study with K. Nillson (Glycorex,
Lund), who manufactures glycan immunoadsorption
columns in human use for ABO-mismatched transplantation (Tyden et al., 2003; Rydberg et al., 2005), and
with E. Samain (Grenoble), who is able to synthesise
gram quantities of GM1 pentasaccharide from glycosyltransferase-transfected Escherichia coli (Antoine et al.,
2003), we are now taking this proposal towards clinical
of GBS, as outlined in Figure 3. Treatment could be
aimed at antibody neutralisation or removal or at suppression of antibody effector function (e.g., inhibition
of complement activation) and key downstream
inflammatory pathways (e.g., chemotaxis and cellular
extravasation). In consideration of the former, antiganglioside antibodies could be (a) removed from the
circulation by immunoadsorption plasmaphoresis, (b)
neutralised with soluble oligosaccharides/glycans, peptide mimics, or anti-idiotypic IVIg, or (c) deleted through
selective plasma cell/B-cell ablation (e.g., by using ricin–
antigen complexes) (Tanemura et al., 2002).
In an approach aimed at antibody neutralisation or
removal, we have identified the minimum epitope
requirements for murine monoclonal antibody and
human anti-GQ1b, anti-GM1, and anti-GD1a antibody
binding and have chemically or enzymatically synthesised these epitopes and related candidate analogues
in collaborations (D. Bundle, Edmonton; A. Bernardi and
S. Sonnino, Milan; N. Bovin and O. Galanina, Moscow)
Journal of the Peripheral Nervous System 10:94–112 (2005)
BTx s100 MAC
Figure 10. Neuromuscular junctions (NMJs) in triangularis sternae muscle preparations from C57/Bl6 mice exposed in vitro to antiGQ1b monoclonal antibody plus human serum as a source of complement, in the absence (A, B) or presence (C, D) of the
complement inhibitor APT070. Post-synaptic membranes are stained with bungarotoxin (BTx). In the absence of APT070 (A, B),
membrane attack complex (MAC) (A, green) is formed that disrupts the nerve terminal and overlying perisynaptic Schwann cell (pSC)
membrane integrity, resulting in loss of neurofilament (NF) (B, green) and S100 (A, blue) staining, respectively. In the presence of
APT070, no MAC is formed and NMJ architecture is preserved with normal NF architecture (D, green) and intact S100-positive pSCs
(C, blue) overlying the nerve terminal. Scale bar ¼ 20 mm (Halstead et al., unpublished data).
use. Substitution of blood group glyco-antigens for
ganglio-series glycans is relatively straightforward, and
prototype columns are currently being constructed. We
are also testing the inhibitory activity of soluble oligosaccharides in ex vivo physiological preparations and in
mouse models in vivo. However, the pharmacokinetics
and glycan metabolism aspects of such an approach in
humans are likely to present greater complexities than
extra-corporeal immunoadsorption, and we thus favour
the former therapeutic strategy.
very long way in a short space of time and opened
up a wealth of potential therapeutic avenues.
Whether the identification of further ganglioside
and glycolipid antigens will lead to new areas for
enquiry remains to be seen. Progress is most
especially needed in the search for the elusive AIDP
antigen(s), and this is the most pressing research
goal in the GBS field. If further advances in identifying
novel glycan antigens are not fruitful, the tables
may turn back to the myelin proteins or other
Schwann cell antigens in the quest for major disease
targets, either as T- or B-cell antigens, and many
preliminary studies suggest that such searches
may be fruitful (Pestronk et al., 1998; Gabriel et al.,
Our advances in understanding the immunopathological pathways underlying GBS have come a
Journal of the Peripheral Nervous System 10:94–112 (2005)
especially confounded by the fact that large trials are
complex and time consuming to organise and execute;
this reinforces the need to make rational choices for
novel immunotherapy testing, informed by basic studies that reasonably reflect the pathogenesis of the
human disease. Such an approach is essential to prevent the GBS field from following false trails or floundering in the therapeutic doldrums well into the 21st
century, especially as other autoimmune diseases
make significant headway by the use of contemporary
The research work described here was supported
by grants from the Wellcome Trust, National Institutes
of Health, Guillain-Barré Syndrome Support Group UK,
and Guillain-Barré Syndrome Foundation International.
The dedicated effort of all the graduate students and
scientific staff in my laboratory over the last decade
who conducted this work is gratefully recognised.
Amongst many external collaborators, particular mention is due to my long-standing collaborator, Dr. Jaap
Plomp, Leiden University, whose electrophysiological
expertise has constantly stimulated and advanced our
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