Epilepsy is one of the most frequent neurological problems. Despite of the advances and improvements in treatment of seizure disorders, immunological alterations such as immunoglobulins and complements have been measured. The levels of IgG in epileptic patients are found to be higher than controls. The levels of IgA, IgM, C3 and C4 were found to be lower in all the controls. Student’s t-test were also applied. Multiple and regression analysis, have been also carried out. A trend has also set up in the present study. An alteration in the immune mechanism of epileptic patients is required. Ketogenic diet may be given and the balance of trace elements like Na, K, Zn, Fe, Ca, Mg and Cu may be maintained to alter the immune mechanism of the epileptic patients. Green leafy vegetables may be given to the patients to control the seizure. Immunity is related with the food we eat. By adjusting the immunity with proper diet the severity of epileptic attack or any disease may be reduced.
Humoral immunity is manifested by the production of antibodies. The antibodies are special chemical substances that react against foreign substances. Antibodies are called as immunoglobulins. Immunoglobulins are serum proteins, which possess antibody activity and which are classified according to the antigens and stimulate their production such as IgA, IgG, IgM, IgD and IgE. In order for antibody to have a cytotoxic effect, an extra substance is required called complement and much has yet to be discovered about its nature and precise functions. The presence of antigens in the body stimulates certain types of defense cells to produce antibodies. Humoral immune response depends on a group of small lymphocytes called B-lymphocytes (B-cells). B-cells originate in bone marrow and travel directly into lymphoid tissues. Cell mediated immunity is directly expressed by certain type of defense against the antigens. These cells are also lymphocytes, but with a slightly different maturation having the influence of the thymus gland. These are called Tlymphocytes in contrast to B-lymphocytes, which produce humoral immunity.
T-cells also originate in bone marrow but unlike Bcells, they do not travel directly into lymphoid tissues, but first enter the thymus where they undergo a conditioning process, hence the name thyms dependent lymphocytes. After leaving the thymus thus migrate to special regions known as thyms-dependent areas, namely the paracortical area of lymph.
It was thought that the central nervous system (CNS) is inaccessible to the immune system in human beings. The concept of immune privilage originated from four historical findings. Ehrlich [
Murphy and Sturm [
Immunocompetence of CNS was under some objections. Adverse immune reactions were recognized and reported in the literature. A rabies virus vaccine pricipitated with a small number of patients and a neuroparalytic illness was found to constitute an autoimmune hyper sensitivity reaction; and an acute disseminated CNS inflammatory disorder precipitated by inoculation with nervous tissue. These findings and favourable outcome of infectious encephalitides and the brisk cerebrospinal (CSF) Pleocytosi, which accompanies brain infection, indicate that immune responses can and must be generated within the brain.
The major role of immune system in the CNS is to protect the host against infection and perhaps also neoplasia. It has been seen that three steps in the protection are first identification of the invaliding microbe or tumor clearance and finally memory for the pathogen so that the immune system may equipped to defend against repeated infections.
CNS and immune system should not be separated but rather as elements of a vast commutation system in which they may exchange information both via an atomic connections and though the hormones and mediators released by hypothalamopituitary axis [5-8]. It is well established that any excessive or uncontrolled immune reaction may be expected to interfere with the brain’s physiology. We may say that any neurologic dysfunction carries the risk of disturbing the delicate equilibrium of the immune network conversely it is true.
This statement is helpful to provide the rationale for the therapeutic concept of immunomodulation of certain immune disorders [
Pharmocologic manipulations of immune pathologies such as rheumatoid arthritis systemic lupus erythmatius etc., by means of neurohormones have been routinely performed.
The process of inflammations increases vascular permeability and allows anti body, complement and other proteins to pass out the circulation and enter the extravaseular space. It may also induce inflammatory cells, including lymphocytes, to cross the vascular endothelium and accumulate in the tissues. Total net effect is to deploy all the resources of the immune system at the site of injury. Cells antibody and complement leave the blood and go into action where the demand is high. It may be in the affected tissue outside the vessel wall.
The effect is to abrogate in CNS, if only temporarily, its isolation from the immune processes of the body. The barrier, which excludes plasma proteins from the brain breaks down, allowing antibody to enter the extra vascular space. The amount of protein in CSF increases and with it the level of immunoglobulin may also change. Immuno competent cells enter the CNS. CNS now becomes capable to generating an immune response [
Lymphocytes accumulate in the CNS in so many inflammatory diseases. They enter from the blood stream, which passed out of the capillary wall between the endothelial cells through altered tight junctions by a process of emperopolesis. Emperopolesis is a process, which describe the behaviour of lymphocytes in tissue culture. They appear to move about inside the cytoplasm of the sebbile cells.
Electron micrograph of the brain shows then travering the endothelial cells of the cerebral capillary. They are enveloped by the plasma membrane and completely surrounded by the host cell, only to extrude on the other side.
Lymphocytes and macrophages entering the CNS accumulate in the Virchow-Rabin space. A sharply demarcated perivascular cuff off inflammatory cells. They may also extend out into the neurophil infiltrating the parenchymal tissue. Similar peri vascular accumulation can be seen in menings large numbers of lymphocytes, which may enter the subarchnoid space.
The permeability of the cerebral vessels to protein may increase as a result of inflammation. The antibody enters the extravascular space. The vascular permeability changes are often transitory and disappear, but the cells continue to enter from the circulation. In the later stages of the disease the vessels may be impermeable to protein although surrounded by densely packed cuff off mononuclear cells. Oldstone et al. [
A vascular leak directly may be seen in human diseases. It changes the composition of CSF. The inflammation may increase the total protein level. This level is found normaly (200 - 400) mg/l and raise in many neurological diseases. CSF protein level is not a measure of the efficiency of the blood brainbarrier (BBB).
Many proteins may have an involvement in the process of fluctuation of their levels independently. It has been seen that some of them may be produced with in the nervous system. Many of proteins may be released from damaged brain tissue. Immunoglobulin may be synthesized within the CNS and boost up the CSF protein level without vascular leak. Albumin is a good marker, which drives from plasma. It is synthesized in the liver and measured by radial immuno diffusion technique. It is found with high concentration in CSF.
It has been reported that in many inflammatory diseases of the nervous system, lymphocytes enter the brain and cord. Both T and B cells may appear in CSF in large amount. It is seen that the percenatage of T cell is increased in many specific conditions compared with that in the blood and the percentage of B cells is reduced reciprocaly.
In acute and chronic infections B-lymphocytes may differentiate into plasma cells. This transformation may be observed in CSF, where all the cells of the lymphoid series may be found, ranging from small, medium and large lymphocytes and immunoblasts to nature plasma cells.
In many neurological diseases the immunoglobulin level of CSF is found to be higher. This feature is often disproportionate to the rise in total protein and it is due to antibody synthesis in the nervous system. It is very well known that the percentage of immunoglobulin in CSF may be raised in many diseases.
It has been found that the proportion between the concentration of a protein in the serum and the CSF remains the same, irrespective of the serum level. Serum IgG and the albumin ratios remain constant and their quotient is also constant as well This has been designated the.
From the equilibrium position reached between CSF and plasma we can calculate the proportion of immunoglobulin entering from the circulation.
The amount of IgG entering from plasma as exudates or transudate cannot be calculated directly. We can get some useful informations from levels of IgG and albumin in the CSF and plasma.
where is equal to the levels of measured in CSF is equal to the levels of measured in Serum is equal to the levels of albumin measured in CSF is equal to the levels of albumin measured in serum We assume that the plasma contribution is made up of two separate elements the normal transudate across the blood brain barrier, supplemented by an exudate or inflammatory leak at the stage of breaking of BBB. we have a situation like
The amount of in the exudate is calculated from the albumin levels in CSF and plasma. It is assumed that these two proteins cross the barrier in a fixed quotient directly related to serum concentration:
and inversely to molecular weight
Albumin in the exudates is estimated by subtracting the amount in the transudate
From the total, allowing the in the exudate to be calculated as follows:
It was believed that only foreign proteins are considered true antigens. Ehrlich [
The distinction between autoimmune response triggered by an infection and inflammation directed against a persistent microbe has been studied by Miller et al. [
Auto immunity may be initiated in the following ways:
1) A self-antigen may be modified and appear as foreign.
2) Ignorant clones may be educated. Microbes may cross-react with self antigens to which the immune system is ignorant. Epitope is at low concentration perhaps. A cross-reacting microbes present in heavy numbers than the original value of antigen and is able to activate and prime T-cells. Once so primed, the original antigen is sufficient to perpetuate the inflammation.
3) Removal of suppression of auto reactive processes. Microbes might cross-react with idiotope and so disrupt the anti-idiotypic network in favour of immunity. The normal regulatory mechanisms of the immune response should restore self tolerance after the initiation of autoimmunity. The maintenance of autoimmune disease must require either multiple rounds of autoimmunity to different self-antigens or a single autoimmune response that is perpeturated by defective regulation. A different form of altered immune regulation is an abnormal cytokine response.
Majority of autoimmune processes are driven by Tcelluler processes. Important exceptions are the anti acetyl choline receptor antibody of mysthenia gravis and antibodies against epithelial adhesion molecules in the bullous skin disease. In the CNS, the pathogenicity of autoantibodies, such as those associated with the paraneoplastic syndrome or stiff man syndrome is not clearly well documented.
It has been seen in many autoimmune disease of the nervous system, driving auto antigen is not known. A treatment is required that makes no assumptions about the provoking antigen and induces antigen -specific tolerance. A short pulse of antigen nonspecific therapy set up a sequence of events leading to the perpeturation of antigen, specific tolerance. This strategy has been used to justify the use of humanized monoclonal antibody. The earlier work on complement deficiency of specific complement components is responsible for a couple of diseases. It is very important to remember that this is similar to the disorders, which occur with selective deficiencies of the immune system [
There are two types of deficiencies of complements: hereditary and acquired.
Acquired deficiencies persist over a long periods and also become causative factor for certain disease. The complement system consists of a series of proteins, there are only a handfull of proteins in the complement system, floating freely in the blood. Complements are created in a person’s liver and are activated by the work with antibodies. Complement cause lysing or brusting of cells and signal to phagocytes that a cell needs to be removed.
Complement are sequentially reacting proteins on activation these proteins mediate a number of biological reactions significant to host defense against bacteria, viruses and other injurious stimuli. Antigen-antibody complexes, bacterial and plant polysacharides and microbial and tissue enzymes initiate the activation. Biological activities mediated by the activated complements proteins or by their fragments include increased capillary permeability, chemotaxis of leukocytes, enhanced phagocytosis, retention of leukocytes at the site of tissue injury and cytolysis. The most thoroughly studied biological complement system has 18 proteins. These are in higher concentration in plasma. The basic role of complement system is mediation of host defense against microbial infection. This goal is full-filled during activation of complement by the elaboration of peptides, larger protein fragments and multimolecular complexes that opsonize and lyse the activating target; induce chemotactic, secretory and metabolic response of leukocytes and alter vascular permeability. These activities constitute an inflammatory response. Fearon, D.T. [
Some of the important phenomena have been studied by Valanakis, J.E. [
2) Cell killing namely, which has the following procedure:
a) Increased vascular permeability;
b) Chemotaxis of leukocytes;
c) Enhanced phagocytosis;
d) Membrane damage.
The limited proteolytic reactions, which characterize the complement system, are essentially not reversible. These reactions lead to cleaved proteins, which are recognized by the body as altered or foreign. These proteins are rapidly cleared from circulation. Despite compensatory increase in synthesis the result is usually a decrease in plasma levels. Thus, an ongoing immunologic event, which is activating the complement system in vivo is likely to generate a decrease in plasma levels of these proteins. Conversely, the abatement of the complement activating stimulus may be paralleled by a reform of the complement levels toward normal has been reported by Stein, J.H. [
The main mediator mechanism of humoral immunity is the complement system. It is an important and essential mechainsm for the destruction both of foreign organisms and immunocomplexes in the presence or absence of specific antibodies. It is a double edged sword and may also destroy host tissue. Fishman R.A. [
Milica, T.C. et al. [
We may see many examples of the direct interactions of the immune system and the brain in patients with epilepsy. There is an increased incidence of epilepsy after stroke, trauma, or infection. These environmental conditions may release brain antigens, stimulate cytokine release, and result in immune activation. Some of the proteins with epilepsy well have a transient worsening of their symptoms with inter current illness. Such worsening does not necessarily imply a CNS infection, but rather an example of the brain’s response to active immune surveillance. Epilepsy is primarily a paroxysmal disorder of brain function. The brain has a special relationship with the immune system. An understanding of this relationship is essential to realize some of the immunological problems meet in epileptic patients.
Bouma, P.A. [
Yabuki and Nakaya [
Dashora, U.K. et al. [
Bostantjopoulou. S., et al. [
De Ponti, F., et al. [
Phenytion, Carbamazepine both attenuate humoral and cellular response. Phenytion, Carbamazepine and Valproate show an immunosuppressive trend and inhibit protein synthesis in lymphocytes decrease IgA and induce changes in IgG and IgM plasma levels. Studies on chornic administration of traditional and new antiepileptic drugs on immune system activity are clearly restricted and warranted. Ranua, J. et al. [
Price P. et al. [
We wish to determine the levels IgA, IgG, IgM, C3 and C4 in epileptic children. Students “t” test will also be applied for the statistical point of view. Multiple correlation coefficient analysis will also be carried out.
We have selected epileptic children whose aged group has a range of zero to twelve years. The patients were on standard medicines. We did not select above this age group. Blood samples of epileptic patients were collected from the Department of Neurology, Safdarjang Hospital, New Delhi 110016 after the approval of ethical committee of the hospital. 10 milliliters freshly drawn blood from each patient was collected in clean and dry test tube without any anti-coagulant. The test tube was kept for 45 minutes at room temperature (22˚C ± 2˚C) for the formation of clot. Sera of different patients were separated by centrifugation at 1500 r.p.m. upto 15 minutes and were collected in screw capped test tubes.
The immunological parameters (IgA, IgG, IgM, C3 & C4) were quantitated by using singles radial immunodiffusion method of Mancini et al. [
We have used a regression analysis regarding the validity of our data. A multiple correlation coefficients analysis has also been applied to the study Regression analysis with different equations has also applied to calculate multiple correlation coefficient.
1) Regression analysis is used to find equations that fit data. Once we have the equation, we can use the statistical model to make predictions. One type of regression analysis is linear analysis. When a correlation coefficient shows that data is likely to be able to predict future outcomes and a scatter graph of the data appears to form a straight line, statisticians may use linear regression to find a predictive function. The equation for a line is
We can take data to calculate linear regression, and we can find the regression equation as
is a way to describe a relationship between two variables through an equation of a straight line, called line of best fit, that most closely models this relationship (
where
and
2) The Simple Multiple Correlation Coefficient (R) is a measure of the strength of the association between the independent (explanatory) variables and the one dependent (prediction) variable. Interpretation of R can be very well explained with the strength of the association: The strength of the association is measured by the sample Multiple Correlation Coefficient, R. R can be any value from 0 to +1. If it is closer R and is equal to one, the linear association will be stronger. If R to zero, then there is no linear association between the dependent variable and the independent variables. Unlike the simple correlation coefficient, r, which tells both the strength and direction of the association, R tells only the strength of the association. R is never a negative value.
This can be seen from the formula below, since the square root of this value indicates the positive root.
Experimental findings along with work carried out by researchers on different modes of analysis and diseases are tabulated in Tables 1-3. Statistical analysis like regression analysis and multiple correlations were also tabulated in Tables 4-7.
We have shown our data on the basis of experimental procedure of Radial immuno diffusion technique of Mancini, G. et al. [
Central nervous system (CNS) is relatively isolated from systemic immune response in the absence of disease. There is no mechanism found for antibody production within the normal condition of CNS. This system has been described as an immunologically privileged site due to paucity of normal immune surveillance. If a virus penetrates the blood brain barrier (BBB) that exclude
Table. 2 Experimental findings along with earlier work carried out by researchers.
most infectious agents, the same barrier may stop viral clearance. Immune responses in the CNS during infection are recruited from the systemic circulation in a relatively selective and specific fashion. Cells and antibodies found in the CNS during infections differ from these that follow non specific rupture in the BBB such as it occurs after a traumatic injury of any type injury may be one of the causes of epileptic attack. In traumatic lesion the transudate of serum contains antibodies and cells of all types enter, but with a predominance of monocytes, which differentiate into macrophases. During the stage of viral infection, we have an early increase in permeability of vessels, which allow transudation of serum proteins, cell entry is immunologically specific. The cells, which are entering have a specific kinetics and do not simply mirror the proportions of cell phenotypes in the blood. These cells in turn are caused to replicate cells, which may persist for long periods of time within CNS. On the basis of the above mentioned facts a review immune response in the CNS is quit necessary and required. Some of the re-
searchers have proposed the hypothesis of immunological mechanism for the involvement of pathogenesis in epileptic attacks. Many of the patient of epilepsy have immune deficient state.
It has been seen that some of the epileptic patients develop auto immune disorders on antiepileptic drugs medication. Many of epileptic patients exhibit different autoantibodies without any clinically manifest autoimmune disorder. The immunological aspects of epilepsy are not confined to the depressive effect of some of the antiepileptic drugs (AEDs) upon the immune system. They also comprise factors relevant to the pathogenesis of some form of epilepsy as well as variety of clinical manifestations met in some patients with epilepsy. The immunologic reactions can be involved in the pathogenesis of some of the epileptic patients is not unexpected. Local immune reaction can give rise to focal cerebral lesions. Focal lesions may develop epileptic attack. It has been established this anti neuronal antibodies lead to epileptic attacks. Immune complexes are trapped in small vessels giving rise to attack of epilepsy. Anti phospholipids antibodies lead to small vascular lesion.
If the antiepileptic effect is due to a direct action upon the brain, the immunoglobulins have to cross the BBB. Many research studies indicate that the BBB has been broken down locally during generalised cerebral seizures. It has been established that the increased expression of proinflammatory molecule has been demonstrated in the brain of epileptic patients after surgery. Inflammatory reactions occur in epilepsy of different types and do not invoke an inflammatory pathophysiology such as temporal lobe epilepsy. Brain inflammation may be a common factor contributing of predisposing to the occurrence of seizures and cell death in different type of epilepsy. We would like to add here that a reversible induction of a selective IgA deficiency might occur in some patients receiving antiepileptic drugs such as Phenytoin. Humoral immunity may alter in patients after the first attack of seizure.
It is believed that the changes in the levels of immunological paramenters in the present study and after the review of the literature are due to manifestation of the factors, which are responsible for this disease. Immunity is related with the food, which we eat. It has already been established that content of the food have some trace elements. The trace elements play a role in human immunity. If the level of these elements goes beyond the limit of normalcy even death may occur. On the other hand if the levels are lower side of the normal range something unnatural can happen. A relation between immunoglobulin, complement and trace element be consider in the future preview of the study.
Granata, T. et al. [
A partial correlation coefficients analysis shows a trend, that is
In the present work an attempt is made to relate the circulatory level of IgG, IgA and IgM and complement C3 & C4 among the subjects undergoing an epileptic attack and comparing them with that of normal individuals.
It has been seen that the conventional antiepileptic treatment have many limitations in the treatment of epileptic cases. Although there has been great advance in the management of the epileptic patients by the application of newly invented developed antiepileptic drugs and surgical techniques. Some of the cases still remain in an interactable position. Immunoglobulin, steroids and ketogeinc diet may be tried and better results may be seen in the treating cases. Immunoglobulin treatment shows benefits in some autoimmune related epilepsy. This treatment has its own limitations in long term efficiency. Steroids show significant improvement in many epileptic syndromes. Ketogenic diet has become one of the most reliable treatment for epileptic children. Ketoegenic diet is difficult to maintain because of low palatability. It shows a very high antiepileptic efficacy. These are some of the suggestive directions to neutralize the effect of the epileptic seizure and try to control. Humoral immunity is altered in children early after the first attack of epilepsy. This may be a consequence of an exogenous event, such as occurrence of infection and related to an interaction of the CNS. The alterations in the immunity of the epileptic patients may be done by the adjusting the level of these in the blood of epileptic patients after the supplementation of proper diet, which is rich in all necessary trace elements. The immunotoxic potential of anticonvulsant drugs appear to be very low. The immunological monitoring is required in all the patients. This monitoring is also required in those patients who are at stage of immune defect.
Our results show that the levels of IgA, IgM, C3 and C4 are lower than controls and the levels of IgG are higher in all the epileptic cases. Statistical analysis shows a trend i.e.
The contributions of all these immunoglobulins are very strong i.e. has a value 0.0996. If we have a higher value of IgG the other values of IgM and IgA will be adjusted according to the application of multiple correlation coefficient analysis. We would like to add here that it is quite possible to have a genetic predisposition to develop IgA deficiency is completely unrelated to the genetic factors involved the pathogenesis of epilepsy. IgA deficiency may appear in many types if epilepsy and irrespective of a family background. Some of the studies showed that the deficiency of IgA occurs in patients with generalized cerebral seizure and some time in partial epilepsies.
Aarli, J. A. [
Our results indicate that there is an altered immune mechanism in epileptic patients needs a modification in the treatment. It can be maintained by the proper supplementation by the ketogenic diet and trace element like Na, K. Zn, Fe, Ca, Mg and Cu. Green leafy vegetables may be given to the patients to control the seizure. Immunity is related with the food we eat. Researches have been made in the direction to increase the immunity with the proper diet. By adjusting the immunity with proper diet the severity of epileptic attack or any disease may be reduced.
The authors are thankful to Dr. P. K. Saxena, Principal, D.A.V. (P.G.) College, Muzaffarnagar for providing the facility of doing work. We are also thankful to Medical Supdt. of Safdarganj Hospital, New Delhi, for arranging the blood samples of the diseased and healthy controls. We are grateful to Dr. Manju Chauhan, Head, Department of Biosciences, D.A.V. (P.G.) College, Muzaffarnagar, for providing the facility of estimation of biological parameters.