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Campylobacter jejuni HS:23 and Guillain-Barre syndrome, Bangladesh.

To the Editor: Guillain-Barre syndrome (GBS) is an acute peripheral neuropathy triggered by a preceding infectious illness. Gastroenteritis caused by Campylobacter jejuni is the most frequently reported antecedent event (1). In Japan, South Africa, China, and Mexico, Campylobacter strains with certain Penner heat-stable (HS) serotypes, including HS:19 and HS:41, are overrepresented among isolates from GBS case-patients, compared with isolates from enteritis case-patients (2,3). Several studies indicate that C. jejuni HS:19 and HS:41 have a clonal population structure and suggest that these serotypes might have unique virulence properties that are intricately linked to development of GBS (4). However, data from the United Kingdom and the Netherlands suggest that such virulence properties may not be restricted to specific HS serotypes because many other serotypes can be cultured from patients with GBS (5). We report a non-HS:19 and non-HS:41 C. jejuni serotype and sequence type (ST)-3219 that are overrepresented among isolates from GBS patients in Bangladesh.

We conducted a prospective case-control study of the serotype and genotype of C. jejuni associated with GBS in Bangladesh. Case-patients were 97 persons with GBS admitted to Dhaka Medical College Hospital, Bangabandhu Sheikh Mujib Medical University, and Dhaka Central Hospital during July 2006-June 2007. All fulfilled the diagnostic criteria for GBS of the National Institute of Neurological Disorders and Stroke of the US National Institutes of Health (Bethesda, MD, USA) (6). The control group comprised 97 patients with other neurologic diseases, matched with case-patients by sex, age, and date of admission to the hospital. A second control group comprised 97 healthy family members of case-patients. Up to 3 stool samples were cultured from each case-patient and control.

Campylobacter strains were presumptively identified with Gram stain, oxidase, and hippurate hydrolysis tests and confirmed with a C. jejuni species-specific PCR. Serotyping was performed at the National Laboratory for Enteric Pathogens, Canadian Science Centre for Human and Animal Health, Winnipeg, Manitoba, Canada. All strains were serotyped according to the HS serotyping schemes of Penner et al. (7). To determine the class of lipooligosaccharides (LOS) locus in each of the C. jejuni strains, genomic DNA was isolated by using the DNeasy tissue kit (QIAGEN, Venlo, the Netherlands). PCR analysis was performed with primer sets specific for classes A, B, C, D, and E (8).

We isolated C. jejuni from fecal samples of 10 case-patients. Campylobacter strains were not isolated from the control groups (p<0.001). Serotyping of the 10 GBS-related strains showed 4 different HS serotypes. C. jejuni HS:23 was found in 5 (50%) strains; HS:19, in 2 (20%); HS:55 and HS:21, in 1 strain each. One strain was untypeable according to the HS typing scheme. In a collection of clinical C. jejuni isolated during the same period from patients with enteritis, HS:23 was encountered in 9 (28%) of 32 patients. Serotypes previously associated with GBS were HS:1, HS:2, HS:4, HS:4/50, HS:5, HS:10, HS:13/65, HS:16, HS:19, HS:23, HS:35, HS:37, HS:41, HS:44, and HS:64 (5,9).

Nine (90%) of the C. jejuni isolates from the case-patients had the class A or class B LOS, which are highly associated with the presence of ganglioside-mimicking structures in LOS (10). Godschalk et al. found that 14 (82%) of 17 GBS-associated isolates possessed a class A/B/C locus (8). Parker et al. (10) found that all GBS-related strains and 64% of the other clinical and environmental isolates belonged to LOS class A/B/C loci. The expression of ganglioside-mimicking structures in Campylobacter, LOS is considered essential for the induction of autoantibodies that lead to GBS. Godschalk et al. (8) demonstrated that specific genes involved in C. jejuni LOS biosynthesis are crucial for the induction of antiganglioside antibodies that lead to GBS.

We performed multilocus sequence typing to examine the overall genomic variation among 10 GBS-related C. jejuni strains. We identified 6 different STs among the GBS-related C. jejuni strains (Table). However, ST3219 has a new combination of alleles and was identified in 4 strains. Concordantly, the analysis demonstrated that C. jejuni isolates with serotype HS:23 were all ST-3219. Of particular interest, ST-985 (BD-67) shared 5 alleles (aspA, uncA, glnA, glyA, pgm) with ST-3219 (Table).

Our findings of a C. jejuni HS:23 serotype and ST-3219 that is highly prevalent among GBS-related C. jejuni strains from Bangladesh are consistent with previous observations that specific LOS types and serotypes are overrepresented among GBS-related C. jejuni strains. These observations support the hypothesis that, although a great variety of C. jejuni serotypes can be isolated from GBS patients in some geographic areas, specific clonal serotypes and multilocus types are prevalent in GBS patients in other places. The association of GBS with C. jejuni LOS class A/B/C is the only consistent finding when universal collections of GBS-associated strains are considered.

This research was funded by the International Centre for Diarrhoeal Disease Research, Bangladesh (ICDDR,B); Erasmus MC, Rotterdam, the Netherlands; and Government of Bangladesh through the Improved Health for the Poor: Health Nutrition and Population Research Project. ICDDR,B also gratefully acknowledges the following donors that provide unrestricted support to the Centre's research efforts: Australian Agency for International Development, Government of the People's Republic of Bangladesh, Canadian International Development Agency, Embassy of the Kingdom of the Netherlands, Swedish International Development Cooperation Agency, Swiss Agency for Development and Cooperation, and Department for International Development, United Kingdom.

Zhahirul Islam, Alex van Belkum, Alison J. Cody, Helen Tabor, Bart C. Jacobs, Kaisar A. Talukder, and Hubert P. Endtz

Author affiliations: International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh (Z. Islam, K.A. Talukder, H.P. Endtz); Erasmus MC University Medical Center, Rotterdam, the Netherlands (Z. Islam, A. van Belkum, H.P. Endtz, B.C. Jacobs); University of Oxford, Oxford, United Kingdom (A.J. Cody); and Laboratory Centre for Disease Control, Winnipeg, Manitoba, Canada (H. Tabor)

DOI: 10.3201/eid1508.090120


(1.) Winer JB. Guillain-Barre syndrome. BMJ. 2008;337:a671. DOI: 10.1136/bmj.a671

(2.) Wassenaar TM, Fry BN, Lastovica AJ, Wagenaar JA, Coloe PJ, Duim B. Genetic characterization of Campylobacter jejuni O:41 isolates in relation with GuillainBarre syndrome. J Clin Microbiol. 2000;38:874-6.

(3.) Nachamkin I, Allos BM, Ho T. Campylobacter species and Guillain-Barre syndrome. Clin Microbiol Rev. 1998;11:555-67.

(4.) Koga M, Gilbert M, Takahashi M, Li J, Koike S, Hirata K, et al. Comprehensive analysis of bacterial risk factors for the development of Guillain-Barre syndrome after Campylobacter jejuni enteritis. J Infect Dis. 2006;193:547-55. DOI: 10.1086/499969

(5.) Endtz HP, Ang CW, van Den Braak N, Duim B, Rigter A, Price LJ,et al. Molecular characterization of Campylobacter jejuni from patients with Guillain-Barre and Miller Fisher syndromes. J Clin Microbiol. 2000;38:2297-301.

(6.) Asbury AK, Cornblath DR. Assessment of current diagnostic criteria for Guillain-Barre syndrome. Ann Neurol. 1990;27:S21-4. DOI: 10.1002/ana.410270707

(7.) Penner JL, Hennessy JN, Congi RV. Serotyping of Campylobacter jejuni and Campylobacter coli on the basis of thermostable antigens. Eur J Clin Microbiol. 1983;2:378-83. DOI: 10.1007/ BF02019474

(8.) Godschalk PC, Heikema AP, Gilbert M, et al. The crucial role of Campylobacter jejuni genes in anti-ganglioside antibody induction in Guillain-Barre syndrome. J Clin Invest. 2004;114:1659-65.

(9.) Nachamkin I, Engberg J, Gutacker M, Meinersman RJ, Li CY, Arzate P, et al. Molecular population genetic analysis of Campylobacter jejuni HS:19 associated with Guillain-Barre syndrome and gastroenteritis. J Infect Dis. 2001;184:221-6. DOI: 10.1086/322008

(10.) Parker CT, Horn ST, Gilbert M, Miller WG, Woodward DL, Mandrell RE. Comparison of Campylobacter jejuni lipooligosaccharide biosynthesis loci from a variety of sources. J Clin Microbiol. 2005;43:2771-81.

Address for correspondence: Zhahirul Islam, Enteric and Food Microbiology Laboratory, Laboratory Sciences Division, International Centre for Diarrhoeal Diseases Research, Bangladesh, Mohakali, Dhaka 1212, Bangladesh; email:
Table. Serotyping and multilocus sequence typing analysis
of Campylobacter jejuni strains associated with Guillain-Barre
syndrome, Bangladesh *

                           LOS         Penner
Strain   Year   Disease   class   type(s) ([dagger])

BD-07    2006     GBS       A           HS:19
BD-10    2006   GBS/MFS     B           HS:23
BD-22    2006     GBS       B           HS:23
BD-27    2006     GBS       A             UT
BD-34    2006     GBS       B           HS:23
BD-39    2006     GBS       A           HS:19
BD-67    2007   GBS/MFS     B           HS:23
BD-74    2007   GBS/MFS     B           HS:23
BD-75    2007     GBS       A           HS:55
BD-94    2007     GBS       E           HS:21

                              Allele, no.

Strain    ST    aspA   glnA   gltA   glyA   pgm   tkt   uncA

BD-07     22     1      3      6      4      3     3     3
BD-10    3219    10     27     33     19    10     5     7
BD-22    3219    10     27     33     19    10     5     7
BD-27    587     1      2      42     4     90    25     8
BD-34    3219    10     27     33     19    10     5     7
BD-39    660     1      3      6      4     54    91     3
BD-67    985     10     27     89     19    10    132    7
BD-74    3219    10     27     33     19    10     5     7
BD-75    587     1      2      42     4     90    25     8
BD-94    2109    4      7      10     4     10     7     1

* LOS, lipooligosaccharides; ST, sequence type; GBS, Guillain-Barre
syndrome; HS, heat stable; MFS, Miller-Fisher syndrome; UT,

([dagger]) Penner HS serotypes.
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Article Details
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Title Annotation:LETTERS
Author:Islam, Zhahirul; van Belkum, Alex; Cody, Alison J.; Tabor, Helen; Jacobs, Bart C.; Talukder, Kaisar
Publication:Emerging Infectious Diseases
Article Type:Report
Geographic Code:9BANG
Date:Aug 1, 2009
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