The Immune System
James Auberle, M.D.
Medical Advisor
Toledo Clinic
4235 Secor Road
Toledo, OH 43623
(419) 479-5534
The immune system is a complex interaction among various organs, blood and lymph glands. Unfortunately, a comprehensive understanding of the variety of immunology topics escapes many physicians and to do justice to it is beyond the scope of this short article. Having stated this, let's discuss some aspects of the immune system and dystonia.
There appears to be no direct connection between the immune system and spasmodic torticollis. However, the immune system reacts or does not react in many other types of conditions. The immune system fights off infections; bacterial, viral, fungal and others. It can sometimes react to forms of cancer and at other times the cancer can be invisible to the immune system. This means that the immune system, when it works properly, is in a delicate balance. It discerns between what it recognizes as foreign and those things that belong in the body. When it detects something foreign, it attacks. It has several different weapons in its battle to fight off the bad stuff. There are cellular mechanisms to engulf bacteria. There are antibodies to attach to viruses. These different forms can act independently and in concert.
Relatively recently in the history of medicine, recognition of the immune system turning on other aspects of the human body has led to a new and different type of disease. These are the diseases of "autoimmunity". The delicate balance of the immune system is askew.
For many of the autoimmune diseases there is often a trigger that starts the process, for example, a viral infection. However, once the viral infection is irradicated the immune system is still stuck in high gear like a light switch stuck in the "on" position. The normal checks and balances that control the immune system from getting out of control simply don't work. These diseases can be organ-specific such as those that may affect the thyroid, or the pancreas e.g., juvenile diabetes mellitus. In other instances, they can affect so many organs they are non-organ specific. Examples of these types of disorders include systemic lupus erythematosus (SLE) and scleroderma. Many of these autoimmune disorders are recognized in neurological diseases such as multiple sclerosis and myasthenia gravis.
In terms of dystonia and ST. there is no direct connection with the immune system. However, it is well known that one of the precipitating factors for dystonia is trauma. When the human body is exposed to short-lived trauma there is a series of biochemical reactions to the stress of the trauma, including activation of the immune system. Long-term trauma or repeated trauma may ultimately tire out the immune system so that it does not work appropriately. Physicians use the term "immunosuppression" when a patient can no longer mount the physiological response to fight off even the normal challenges of life.
Where the immune system comes into play in the treatment of ST is in the use of Botulinum toxin. Botulinum toxin is an important treatment option for many dystonia patients. It is a large protein poison that if the human body gets exposed to will stimulate the immune system to produce antibodies to inactivate the poison so that it does not cause damage. The larger the amount of botulinum toxin injected or the more frequently the injections the more likely there will be antibodies that are produced that may inactivate the toxin. Therefore, in order to minimize the effect of the immune system in the inactivation of the botulinum toxin we attempt to use the minimum amount of toxin to get good clinical effect and to keep the injections as far apart in time as is clinically reasonable. Hopefully, following these guidelines will not stimulate the immune system and, instead, will allow the treatment of dystonic conditions for many years. As far as can be determined, there have been no long-term consequences from the use of botulinum toxin which has been in use since the late 1970's .
In summary, there appears to be no direct involvement of the immune system in the causes of dystonia and spasmodic torticollis. If it has any role whatsoever in those patients who have some degree of trauma in their respective past, it may have an indirect and unknown relationship with this movement disorder. However, in terms of the treatment options in the use of botulinum toxin, it may play a key and critical role in how patients are given this medication. In terms of the immune system, more is not always better. Botulinum toxin use for the long haul should be given in the smallest doses that are practical and as far apart between injections that are practical. What is practical? That is what you and your respective physician need to decide.
