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Original Paper
Neuroepidemiology 1998;17:296–302
Emilia-Romagna Study
Group on Clinical and
Epidemiological Problems in
Neurology 1
Campylobacter jejuni Infection and
Guillain-Barré Syndrome:
A Case-Control Study
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Key Words
Guillain-Barré syndrome
Campylobacter jejuni
Case-control study
Abstract
We performed a case-control study to investigate the association between Campylobacter jejuni (CJ) infection and Guillain-Barré syndrome (GBS) or Miller-Fisher syndrome. We
compared 60 cases with 109 hospital controls matched for age,
gender, hospital and geographical location.To diagnose the CJ
infection, we considered the association between serologic
positivity for CJ and a previous diarrheal illness within 3
months of inclusion in the study. Fifteen percent of cases versus 5% of hospital controls had CJ infection (p ! 0.003, OR =
3.96, 95% CI: 1.08–17.85). However, CJ infection was related
to GBS only if it occurred during the previous month (p !
0.001, OR = 7.29, 95% CI: 1.43–71.28). No statistical differences were found between the cases who were positive for CJ
infection and those who were negative for CJ infection when
studied by stepwise multivariate logistic regression for age,
gender, clinical and electrophysiological features and outcome. Recent CJ infection may be a risk factor for GBS.
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Introduction
ABC
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Campylobacter jejuni (CJ) infection may
be an important antecedent of the GuillainBarré syndrome (GBS). However, the clinical
and epidemiological features of this associa-
Roberto D’Alessandro, MD
Institute of Neurology, Neuroepidemiology Unit
via Foscolo, 7
I–40128 Bologna (Italy)
Tel. +39 51 644 2203, Fax +39 51 644 2165
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The study was presented at the Regional North American
Annual Meeting of the World Federation of Neurology, Research Group on Neuroepidemiology, Boston, April 18, 1997.
Supported by MURST 60%.
1
For details see p. 301.
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tion need to be clarified. First, the frequency
of CJ infection in GBS patients ranges from
14% [1] to 66% [2] in case-control studies,
from 4% [3] to 49% [4] in clinical series or up
to 67% [5] in pure motor GBS patients. Second, the finding that CJ infection is associated primarily with axonal-motor GBS, a more
severe form with a poor outcome, is controversial [3, 6–10]. Methodological limitations
of previous studies may account for disparate
results. While numerous case reports [6, 11–
16] and case series [4, 7, 9, 10, 17–19] have
been performed, few case-control studies [1,
2, 8] have been published. Furthermore, no
study has been based on incident GBS cases
to avoid possible selection bias concerning
disease severity. Another important point relates to the diagnosis of CJ infection in GBS.
Since most CJ infections are self-limited with
a brief period of bacterial excretion, stool cultures are often negative if performed late [20,
21] and the diagnosis of CJ infection in GBS
is based on serologic findings. However, serologic assays, the various systems for CJ typing
and the criteria of CJ infection are not homogeneous. We report findings of a case-control
study using a clinical and immunological definition of CJ infection.
Methods
Study Population. Patients were recruited from a
prospective, multicenter study on the incidence and
prognosis of GBS and Miller-Fisher syndrome (MFS)
in the Emilia-Romagna region of northern Italy, during the years 1992–1993 [22]. We enrolled 94 patients
(87 GBS, 7 MFS) among 3,909,512 inhabitants. Of
these, 17 were not eligible for the study as they were
recruited from two centers which participated in the
incidence study only. Inclusion criteria for cases were:
(1) fulfillment of diagnostic criteria of the National
Institute of Neurological and Communicative Disorders and Stroke [23] for GBS or the MFS variant of
GBS (e.g., areflexia, ophthalmoplegia and ataxia) [24],
and (2) onset of GBS or MFS within 1 month prior to
Campylobacter jejuni Infection and
Guillain-Barré Syndrome
entry into the study. Two hospital-based controls
matched for gender, age B 5 years, hospital and geographical location were identified. Hospital controls
(HC) had to be admitted to the same hospital as the
patient within 1 month after the case admission for an
acute disease other than peripheral neuropathy and
unrelated to the following clinical factors: fever over
37.5 ° C, upper airway infection, vomiting, diarrhea,
vaccination, surgery, dialysis, blood transfusion, and
plasma exchange.
Data Collection. For each patient, data was collected for clinical features, electrophysiological findings, disease severity as graded by the scale of Hughes
et al. [25] and follow-up for at least 6 months. The electrophysiological study included the following minimal
requirements: motor conduction velocity and sensory
conduction velocity of the ulnar nerve, sensory conduction velocity of the sural nerve, motor conduction
velocity and F wave study of the peroneal nerve on
both sides. Because of the lack of uniformity in reference values among the laboratories of the participating
centers, each one classified the amplitude of the compound muscle action potential as normal or reduced (a
reduction below the lower limit of normality) and classified the findings of the electrophysiological study as
normal, axonal, demyelinating, or mixed (i.e. both features) [22]. The Hughes scale includes six different
degrees of disease severity: grade 0 = healthy; grade 1 =
minor signs or symptoms but able to do manual work;
grade 2 = able to walk without support but incapable of
manual work; grade 3 = able to walk with support;
grade 4 = bed-confined or chair-bound; grade 5 =
requiring assisted ventilation; grade 6 = dead. Information on the above clinical factors within the previous 3 months was collected for both patients and HC
by a self-administered questionnaire whose reliability
with respect to direct interview showed an almost perfect agreement for the majority of items. Blood and
stool samples were obtained, whenever possible, from
each case and HC within a few days of hospital admission.
Serologic Methods. The sera were stored frozen
until the serologic assays were done. Campylobacter
antibodies of the immunoglobulin IgG class were determined by enzyme-linked immunosorbent assay
(ELISA) with acid glycine extract antigen as previously
described [26]. CJ PEN 19 grown for 2 days was harvested in saline, centrifuged, washed in phosphatebuffered saline (PBS) and then treated with 0.2 M glycine-HCl (pH 2.2), neutralized with NaOH, dialyzed
against H2O for 24 h and finally concentrated by ultrafiltration. Microtiter plates were coated overnight at
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4 ° C with 1 Ìg/ml of antigen/well. Before use, microtiter plates were washed 5 times with PBS-Tween
(0.05%)-fetal calf serum (FCS, 1%) and incubated at
37 ° C for 1 h. All serum samples and negative and positive control sera were used at a dilution of 1:100, distributed in duplicate at a volume of 100 Ìl/well, incubated 30 min at 37 ° C, washed 3 times with PBSTween-FCS and then 100 Ìl of peroxidase-conjugated
rabbit antihuman IgG (diluted 1:1,000) was added.
Plates were incubated at 37 ° C for 30 min, washed
once with PBS-Tween-FCS and then the substrate (ortho-phenylenediamine 2 HCl; Ortho Diagnostic Systems Inc., Raritan, N.J., USA) was added. The reaction was stopped by the addition of H2SO4 and the
optical density (OD) at 492 nm was read in a Microwell System-Reader 510 (Organon Teknika Corp.,
Durham, N.C., USA). Sera of 100 blood donors,
screened by immunoblotting technique for the reaction with the polypeptides of CJ PEN 19, were used as
negative and positive controls. Positive results were
defined as an OD value exceeding the mean plus two
standard deviations (SD) of the OD-negative control
values. Antibodies to GM1, GD1b, GD1a, GQ1b, and
GM2 were detected through ELISA, using a standardized protocol [27]. Antibodies to a certain ganglioside
were considered positive when the mean difference of
absorbance at 450 nm at a titer of 500 was higher than
0.100. Positive samples were further titrated and the
titer expressed as the highest with a difference of absorbance 1 0.050.
Microbiologic Investigation.The stool samples were
suspended in saline and seeded onto Campylobacter
blood-free medium base (Biolife) with antimicrobic
supplement (Biolife) according to Karmali et al. [28].
The plates were incubated for 48 h at 42 ° C in a
microaerophilic atmosphere utilizing Gas Pak jars and
Campy Pak envelopes (BBL).
Criterion for CJ Infection. CJ infection was defined
as a positive serologic result for CJ when associated
with a definite history of a diarrheal illness within the
previous 3 months.
Statistical Methods. Exposure to CJ infection in
cases and HC was compared by the odds ratio estimated from exact logistic regression. If data on exposure for some individuals were missing, all possible
patterns of exposure were considered separately, yielding separate models. Thus in the case of 1 HC with
missing data, this patient would be considered exposed
(first model) and unexposed (second model) to the
infection. Exact stepwise multivariate logistic regression was then used to construct a model to discriminate between the positive and negative CJ infection
298
Neuroepidemiology 1998;17:296–302
group on the basis of age, gender, clinical and electrophysiological features and outcome. If no discriminating factors were found, the univariate odds ratio was
reported.
Results
Of the 77 cases initially eligible for the
study, 17 were excluded for the following reasons: 10 lacked HC, 4 had been observed
more than 30 days after GBS onset, and 3 had
a known underlying cause of GBS (HIV infection). Sixty cases, of whom 37 were men, participated in the study. Fifty-five of the cases
had GBS and the remaining 5 had MFS. At
the first examination, 30% of the cases had
mild disease (grade ^2 on the Hughes scale)
while 8% required ventilatory support. Of the
109 HC, there were 2 each for 49 cases and
only 1 for 11 of the cases. Blood samples were
collected from 59 cases (99%) and 96 HC
(88%). Stool specimens were available in 53
patients (88%) and 73 HC (67%). No cases
had positive stool cultures for CJ and the only
one HC had a positive serology for CJ and a
previous history of diarrheal illness.
Serologic Findings and Frequency of
Diarrheal Illness
A positive serologic test for CJ was detected in 36 (61%) out of 59 cases and in 56
(58%) of the 96 HC. A diarrheal illness within
the previous 3 months was found in 15 (25%)
of the 60 GBS patients compared with 17
(16%) of the 109 HC. Within the previous
month, it was noted in 11 cases (18%) as compared with 12 HC (11%).
CJ Infection
One of the 60 cases and 13 of the 109 HC
refused to cooperate for blood draws. All subjects were classified, however, on the basis of
clinical criteria for CJ infection. One case and
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12 out of 13 HC lacking blood samples did not
present any history of previous diarrheal illness, and were classified in the non-CJ infection group, independently of the serologic results. The last HC had a definite history of
diarrheal illness and therefore was considered
in the analysis as both exposed (first model)
and unexposed (second model) to the infection.
Nine patients (15%) had CJ infection, as
compared with 5 HC (5%, p ! 0.03, OR =
3.96, 95% CI: 1.08–17.85, first model) or
4 HC (4%, p ! 0.02, OR = 4.29, 95% CI: 1.19–
19.16, second model). When considering the
occurrence of CJ infection in the last month
before the study inclusion, 8 cases (13%) versus 3 HC (3%, p ! 0.01, OR = 7.29, 95% CI:
1.43–71.28, first model) or 2 HC (2%, p !
0.006, OR = 8.00, 95% CI: 1.59–77.24, second model) were affected. When considering
the occurrence of the infection in the 2nd and
3rd months before inclusion in the study, 1
case and 2 HC were affected (OR = 0.91; 95%
CI: 0.02–17.77). Overall, the cases had presumed CJ infection at a time interval near to
neuropathy onset, ranging from 6 to 35 days
with a mean of 16 days, in contrast with the
HC who had a mean of 37 days (range: 7–61
days) before inclusion in the study.
Characteristics of the Positive and
Negative CJ Infection Groups
The 9 cases with CJ infection included 5
men and 4 women. Only 1 case had MFS. Age
ranged from 22 to 77 years (mean B SD: 45.6
B 21.2). The duration of diarrheal illness
ranged from 1 to 12 days (mean of 4.5 days).
The mean interval between diarrhea onset
and venesection for serologic study was 19
days (range: 8–39 days). All but 1 of these
cases received therapy: plasma exchange in 3
and high doses of immunoglobulins in the
remaining 5.
Campylobacter jejuni Infection and
Guillain-Barré Syndrome
Out of 9 patients with CJ infection 3
showed reactivity to one or more gangliosides:
1 GBS case was positive for both anti-GM2
and anti-GM1 antibodies; 1 for anti-GD1a
antibodies; and 1 MFS case was positive for
anti-GQ1b antibodies.
We compared the positive CJ infection
group (9 cases) with the negative CJ infection
group (51 cases) by a stepwise multivariate
logistic regression analysis. None of the following variables were significant: age above
or below the median (58 years, OR = 0.45,
95% CI: 0.06–2.39), gender (56% men vs.
63%, OR = 0.74, 95% CI: 0.14–4.24), the proportion of MFS, upper airway infection during the preceding 3 months, disease severity
(grade 63 on the Hughes scale) at nadir, need
for ventilatory support, and pure axonal neuropathy alone or coupled with a mixed neuropathy (both axonal and demyelinating). In
regard to outcome, we considered improvement of at least 1 degree on the Hughes scale
at 1 month, recovery (grade = 0 on the Hughes
scale) and mortality at 6 months after neuropathy onset. Both the positive and negative CJ
infection groups had a good outcome on the
Hughes scale with a high rate of improvement
at 1 month, about 60% recovery at 6 months
and a very low mortality, without a significant
difference. These factors did not discriminate
between the two groups by means of the odds
ratio. The univariate odds ratio of clinical and
electrophysiological features and outcome are
summarized in table 1.
Discussion
Our case-control study was performed on
incident cases of GBS and MFS. The HC
represented a control group matched not only
for age and gender, but also for hospital and
geographical location.We could not use stool
cultures to diagnose CJ infection because the
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Table 1. Positive versus negative CJ infection group: Univariate odds ratio (OR) and 95% confidence interval (CI)
MFS
Upper airway infection
Grade 63 at nadir1
Ventilatory support
Pure axonal neuropathy
Pure axonal and mixed neuropathy
Improvement at 1 month2
Recovery at 6 months3
Death at 6 months
2
3
Negative CJ
infection group
(cases = 51)
n
%
n
%
1
6
7
1
0
4
7
5
1
11
67
78
11
0
44
78
56
11
4
26
37
9
3
20
38
29
2
8
51
73
18
6
39
75
57
4
95% CI
1.46
1.90
1.32
0.59
1.45
1.24
1.19
0.94
2.98
0.03–17.58
0.36–13.05
0.21–14.48
0.01–5.44
0.00–14.54
0.22–6.53
0.19–13.20
0.18–5.38
0.05–63.90
On the Hughes scale.
At least 1 degree on the Hughes scale.
Grade 0 on the Hughes scale.
frequency of missing samples was high and of
questionable diagnostic value [20, 21]. However, among all subjects tested, only 1 HC presented with positive stool cultures. Serologic
evidence could also occur in a carrier state or
exposure without active infection [3, 29] and,
currently, it is not known if GBS can also
occur under these conditions. Therefore, we
also considered the occurrence of a previous
active diarrheal illness and preferred to use a
more restrictive criterion to exclude false positive cases. We found that 15% of cases had
CJ infection versus 5% of HC. The difference
was significant and in agreement with other
case-control studies [1, 2, 7–10, 18]. This suggests that CJ infection represents a risk factor
for GBS, that occurs with a relatively low frequency.
To establish whether the time interval between CJ infection and GBS onset conditioned the appearance of the neuropathy, we
studied the date of the infection preceding
300
OR
Neuroepidemiology 1998;17:296–302
GBS onset. The significant association between CJ infection and GBS appears to depend on its occurrence in the month prior to
the clinical disease. In contrast with HC, cases
had enteritis in a time near to GBS onset:
8 patients within 30 days, the other at about
35 days. Thus, it seems that only a recent CJ
infection may heighten risk for GBS.
Our frequency of CJ infection could be an
underestimate because we did not test Penner
strains other than Penner 19. The latter is
considered the most frequent CJ serotype.
However, when considering two case-control
studies that adopted methods similar to ours,
our frequency (15%) is similar to that reported by Winer et al. [1] (14%), but lower
than that reported by Rees et al. [8] (26%). In
the latter study, however, if only those GBS
patients with CJ infection (27/103) who also
had had a previous diarrheal illness (n = 19)
were selected by applying our criterion of CJ
infection, the frequency would be only 18%. A
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1
Positive CJ
infection group
(cases = 9)
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comparison of other case-control studies is
difficult because the populations studied, the
serologic methods and the criteria for CJ
infection were different. Enders et al. [10]
reported a frequency of 39%, when testing the
Lior and not the Penner serotype. The studies
of Jacobs et al. [9] (32%), Mishu et al. [18]
(36%) and Kaldor and Speed [7] (38%) used
serologic evidence alone. A possible selection
bias could be present in the studies by Mishu
et al. [18] and Kaldor and Speed [7], since
their cases were recruited from University
centers and from infectious disease centers,
respectively. Finally, the highest proportion
ever reported (66%), found by Ho et al. [2],
could reflect a higher frequency of CJ infection in that region as evidenced by the high
rate of seropositive controls (16%).
For CJ serologic positivity, we found high
rates both in GBS cases (61%) and HC (58%).
This suggests that CJ infection may be overestimated on the basis of the serologic findings
alone. It seems, therefore, that an active infection is necessary to trigger the immunological
mechanism which could lead to GBS, rather
than simple exposure to CJ or a carrier state.
In addition, we found that enteritis in the previous 3 months or 1 month is not a risk factor
for GBS. Instead, the diarrheal illness becomes significantly related to GBS when
caused by CJ. One of our patients with CJ
infection had MFS, in agreement with previous results [8, 30] that this variant form of
GBS could also be associated with CJ. The
comparison between positive and negative CJ
infection groups did not yield a predictive
model containing any of the following variables: age, gender, clinical and electrophysiological features, and outcome. Thus, we did
not find that GBS associated with CJ infection is a more severe form with poorer outcome. As our sample size was relatively small,
our findings need to be replicated in large
scale studies.
Campylobacter jejuni Infection and
Guillain-Barré Syndrome
Emilia-Romagna Study Group on
Clinical and Epidemiological Problems
in Neurology
Coordinating Members: M. Guarino, M. Casmiro,
R. D’Alessandro.
Participating Centers: A. Ravasio, M. Pasquinelli,
B. Currò Dossi (Department of Neurology, Rimini);
W. Neri, C. Guidi, M. Gessaroli (Department of Neurology, Forlı̀); G.G. Rebucci, G. Padoan, C. Callegarini, G. Ciucci, A.R. Guidi (Department of Neurology,
Ravenna); G. Facchini, M. Galeotti (Department of
Neurology, Lugo); M. Casmiro, G. Bianchedi (Department of Neurology, Faenza); M.R. Tola, V. Govoni, E.
Granieri (Institute of Neurology, University of Ferrara); G. Tralli, V. Tugnoli (Department of Neurology,
Ferrara); V. Mussuto (Neurology Service, Imola); M.
Guarino, R. Rinaldi, L. Fiorani (Neurology Service, S.
Orsola-Malpighi Hospital, Bologna); A. Baldrati, S.
Laudadio, T. Sacquegna (Department of Neurology,
Maggiore Hospital, Bologna); F. Salvi (Department of
Neurology, Bellaria Hospital, Bologna); R. D’Alessandro (Institute of Neurology, Neuroepidemiology Unit,
University of Bologna); V. Miele, V. Lolli, M. Santangelo (Department of Neurology, Carpi); L. Motti, D.
Guidetti, F. Solimè (Department of Neurology, Reggio
Emilia); F. Granella, G. Pavesi, I. Allegri, L. Falco (Institute of Neurology, University of Parma); A. Scaglioni, E. Montanari (Department of Neurology, Fidenza); S. Cammarata, V. Poli (Department of Neurology, Piacenza).
Microbiologists: O. Varoli, C. Mazzoni (Department of Experimental and Specialist Clinical Medicine, S. Orsola-Malpighi Hospital, Bologna).
Immunological Studies: A. Lugaresi (Institute of
Neurology, University of Chieti).
Statistician: L. Bassein (Department of Clinical
Pharmacology and Therapeutics, S. Orsola-Malpighi
Hospital, Bologna).
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