Book Review

Immunological and Infectious Diseases of the Peripheral Nerves

N Engl J Med 1999; 340:325January 28, 1999

Article

Immunological and Infectious Diseases of the Peripheral Nerves
Edited by N. Latov, John H.J. Wokke, and John J. Kelly, Jr. 435 pp., illustrated. New York, Cambridge University Press, 1998. $145. ISBN: 0-521-46265-7

For much of their length, peripheral nerves are protected against the immune system by tight capillary endothelial junctions and perineurium. However, this protection is only relative. Lymphocytes, immunoglobulins, complement components, viruses, and toxins can gain access to motor nerves at their termination in skeletal muscle and to sensory nerves at the level of the dorsal-root ganglion. Such access can be a recipe for trouble, since peripheral nerves contain molecules that very suitably serve as autoantigens, such as myelin-specific lipids and proteins, and microglia-like cells that can present antigens to lymphocytes. Immune-mediated damage to the peripheral nervous system may occur in isolation, as in the Guillain–Barré syndrome, or as a component of a multisystem disorder, as in periarteritis nodosa. Immune damage in a nerve can be set in motion by an infection (e.g., lepromatous leprosy or Lyme disease), a neoplasm (e.g., the Lambert–Eaton myasthenic syndrome), or a connective-tissue disorder (e.g., rheumatoid arthritis).

The clinical presentations of immune-mediated peripheral nervous system disorders include symmetric distal polyneuropathy, selective involvement of one or more peripheral nerves, and pure dysfunctions of autonomic nerves or neuromuscular junctions. Diagnosis can be straightforward. For example, polyneuropathy that is rapidly progressive, is symmetric, and involves motor nerves more than sensory nerves in an otherwise healthy person is likely to be the Guillain–Barré syndrome; mononeuropathy multiplex in a person with evidence of renal and pulmonary involvement is often due to vasculitis. Measurements of nerve conduction velocity serve as a helpful extension of the clinical examination, making it possible to distinguish between demyelinative disorders and axonal disorders. Serologic studies (e.g., titers of antibodies in Lyme disease and human immunodeficiency virus infection) are often invaluable in making a specific diagnosis, as is histologic detection of amyloid or necrotizing arteritis.

Immunological and Infectious Diseases of the Peripheral Nerves is a valuable resource for clinicians involved in the diagnosis of neuromuscular disorders and care of patients with these diseases. The chapters are by experts and have been carefully and consistently formulated to cover the clinical, pathophysiologic, and therapeutic aspects of essentially all the known immunologic and infectious diseases affecting the peripheral nervous system. Despite the many authors, there is very little redundancy. The illustrations are, in general, well chosen, though the reproduction of histologic figures suffers somewhat from the paper stock and the lack of color. The chapters are well referenced with key articles, which in general were published through 1996 or the beginning of 1997. The book provides a well-structured appreciation of this group of peripheral nerve disorders. At least in my case, the opportunity to read through the book is likely to translate into a greater capacity to diagnose and manage illness in my patients.

David Pleasure, M.D.
Children's Hospital of Philadelphia, Philadelphia, PA 19104