Archive for September, 2018

Post Treatment Lyme Disease Unmasked? Immune Hole in the Illness Identified

It’s one of the bigger puzzles in medicine and one that has obvious implications for chronic fatigue syndrome (ME/CFS): why some people given oral antibiotics recover from Lyme disease while others sometimes remain sick for decades. Given the infectious trigger often seen in ME/CFS, any post-viral or post-bacterial illness is of interest. For the most part, researchers don’t know why some people fail to recover fully from an infection; they’ve hardly touched the subject, but an answer in Lyme disease may be coming.

The Study

The study was not large, containing 32 patients and 18 healthy controls, but the results were exciting, providing for the first time a possible biological explanation for the puzzling problem of post-treatment Lyme disease syndrome (PTLDS).

targeted approach Lyme

The ability to target a specific part of the immune system was the key to this studies success.

It’s not taking away anything from the researchers that the study wasn’t particularly innovative. In fact, it did something rather obvious, something that’s been done and is being done in ME/CFS (by Lenny Jason). The study took people with early Lyme disease (n=32) and healthy controls (n=18) and then (after providing the standard antibiotic regimen) followed them over two years, measuring their immune status.

The difference between this successful Lyme disease study and the less successful ME/CFS studies that measured cytokines, gene expression, and autonomic functioning is that the Lyme researchers had a clear target. Mouse studies have shown that the Borrelia burgdorferi bacteria that cause Lyme disease hammer the B-cells, and that’s what the study focused on.

Results

We herein identify plasmablasts as a key B cell population that correlates with resolution of Bb infection and Lyme disease in humans. The authors

They found that B-cells called plasmablasts were elevated prior to antibiotic treatment in patients who returned to health.  Plasmablasts are activated B-cells which circulate for a time in the blood in response to an infection.  The higher level of plasmablasts in the recovered patients suggests that these patients simply mounted a stronger immune response to the infection. That was kind of a no-brainer, but the strength of the study was that they were able to specify what part of our amazingly complex immune system the problem was in.

They also determined that the patients who returned to health also exhibited significantly greater clonal expansion: their activated B-cells produced more clones designed to target and get rid of the bacteria. Again, in retrospect, not a surprising finding, but one that does open up a possible treatment option that hasn’t previously been available.

b-cell Lyme disease

A type of B-cell called a plasmablast turned out to be the key.

Along the way this group also produced a possible diagnostic test which may a) be able to identify Lyme disease infections very early on and b) have high rates of accuracy.  The current Lyme tests do neither; they’re only about 50% accurate during the early stages of infection when studies show treatments are most effective.

They also demonstrated that Lyme disease prompts the expansion of a type of memory B-cell (CD27−) associated with some infections and, more commonly, with autoimmune diseases (rheumatoid arthritis, lupus and multiple sclerosis).

Possible Therapy

Finally, the results point to an unexpected potential therapy – monoclonal antibody drugs. Monoclonal antibody drugs (the “mabs”, e.g. Rituximab) can be theoretically designed to trigger the immune system to target any cell in the body or to influence how the immune system works in other ways. In cancer, for instance, many monoclonal antibodies have been produced that target specific cancer cells. In autoimmune diseases such as rheumatoid arthritis, Crohn’s disease and ulcerative colitis, monoclonal antibodies bind to and inhibit the pro-inflammatory cytokine TNF-a.

Over 75 monoclonal antibody drugs have been approved by the FDA.  Only one, interestingly, specifically has targeted an infection (HIV).  These drugs have, however, recently been effectively used in Ebola and syncytial virus infections.

The authors suggested that Borrelia burgdorferi (Bb)specific monoclonal antibodies could whack the bacteria hard enough to allow doxycycline to work in all patients, not just those with more robust B-cell responses.  In fact, recent developments in monoclonal antibody production suggest that an anti-Lyme drug could be used prophylactically to provide protection against the bug.  The limiting factor may be expense, but recent developments may bring the cost of these drugs down.

Prospecting in Chronic Fatigue Syndrome (ME/CFS)

This study indicates that prospective studies – studies which follow a population over time as some fall ill – can work really well if the study target is focused correctly.  Starting back with Dr. Lloyd’s Dubbo studies several have been done in ME/CFS. None have achieved the results that this Lyme study did, but they have been illuminating.

The Dubbo studies followed 253 people for 12 months after they were infected with one of three pathogens (EBV, Ross-River Virus, Coxiella burnetii). That 11% met the CDC criteria for ME/CFS after six months indicated that long standing illnesses after serious infections were surprisingly common.  Attempts to figure out why a significant number of people remained ill were largely ineffective though.

Some of the studies were quite small and are probably not conclusive but they suggested that neither increased herpes viral titers (herpes virus reactivation) nor changes in 35 cytokines nor gene expression nor psychological factors played a role.

Dubbo studies

The Dubbo studies found that the severity of the initial infection played a role in who failed to recover from an initial infection.bo

The only finding that initially stood out was the severity of the initial infection. People with more severe symptoms initially were significantly more likely to come down with ME/CFS.  In 2008, however, the group found a possible genetic underpinning for the disease; it turned out that polymorphisms (unusual formations) in genes coding for two cytokines (IFN-y, IL-10) affected how ill a person got and how long they remained ill. The findings suggested that a genetic predisposition for an increased inflammatory response might be tipping some people over into prolonged illnesses.

In 2009 Vollmer-Conna, a member of the Dubbo group, working outside ME/CFS found more evidence that one’s immune status makes a difference. She found immune status prior to surgery significantly affected one’s immune functioning, distress levels and ability to recover after surgery.

Next Jason and Katz began a large study of adolescents that came down with infectious mononucleosis (IM). They found no evidence that reductions in peak work capacity, or activity levels, or problems with orthostatic intolerance,  or reductions in salivary cortisol or natural killer cell number and function played a role in an adolescents inability to recover from IM.  The study, however, did suggest that early damage to autonomic nervous system, to the ability to consume oxygen, as well as psychological factors and differences in cytokine networks  were present in those who failed to recover from IM.

Another Jason-Katz study which did not examine biological factors other than autonomic nervous system functioning found, as did the Dubbo study, that the severity of the initial infection – and the amount of bed rest it prompted – played the most significant role in who remained ill. Psychological factors such as “perceived stress, stressful life events, family stress, difficulty functioning and attending school, family stress, and psychiatric disorders” had no impact.

In 2013 Jason, Katz and others began an even larger study which tracked college students after coming down with infectious mononucleosis. They’ve collected blood samples from and have been following over 4,000 college students over the past couple of years. About 5%  contracted infectious mononucleosis, a common trigger for ME/CFS. Grants applications are being written to further assess autonomic functioning, as well as cytokine, metabolome and saliva biological risk factors..

If Jason et. al. have picked the right target, this fascinating study could tell us more about what goes wrong when someone gets ME/CFS. If it doesn’t then their samples –  banked in liquid nitrogen at -80 degrees C –  provide a potentially invaluable resource for the future.

By capturing the blood of people with ME/CFS before they got sick, as they were getting sick and then after the illness became established, Jason’s unique biobank could allow future researchers to quickly determine if the factor they believe plays a critical role in ME/CFS does – saving much time and money.

Small Non-profit Potentially Makes Big Difference

Showing that you don’t have to be large to potentially make a major difference, this potential Lyme breakthrough came not from the NIH or the CDC but from a small Lyme non-profit – The Bay Area Lyme Foundation  – that’s been in business for just over five years.  The study was the product of an 2014 award, The Bay Area Lyme Foundation Emerging Leader Award, that went to Lisa Blum, PhD, a former Stanford postdoc. That award specifically targets veteran researchers who have not previously worked in Lyme research.

The Simmaron Research Foundation is another non-profit that is seeking to scientifically redefine how a disease is understood and treated.  It is currently funding studies that are using proteomics and metabolomics to study cerebral spinal fluid in ME/CFS, that are assessing the effectiveness of underutilized treatments such as Ampligen, IVIG and Cidofovir, and that are seeking to understand why the rate of a lymphoma is increased in ME/CFS.

Could the Brain’s Mast Cells Be Causing Chronic Fatigue Syndrome (ME/CFS)?

“We propose that stimulation of hypothalamic mast cells by environmental neuroimmune pathogenic and stress triggers activates microglia leading to focal inflammation in the brain and disturbed homeostasis.” Theoharides et. al., 2018

Dr. Theoharis Theoharides is an MD and PhD who has published almost 400 papers. A pioneer in the field of mast cell research, Theoharides runs the mastcellmaster.com website and has produced a line of dietary supplements to tamp down mast cell activity. Just a couple of days ago he led an NIH sponsored workshop “Mast Cell Triggers and Mediators Beyond Allergy and Tryptase”.

Recently he took up the subject of chronic fatigue syndrome (ME/CFS), energy metabolism and mast cell activation in a paper “Myalgic Encephalomyelitis/Chronic Fatigue Syndrome-Metabolic Disease or Disturbed Homeostasis?

First Theoharides examines the idea that problems with energy metabolism are causing ME/CFS. He agrees that the energy problems ME/CFS patients experience are due to problems with energy depletion, stating that, “Much evidence suggests that the pathophysiology of ME/CFS is highly associated with alterations in normal energy metabolic processes and abnormalities in cellular bioenergetics”, but then spoils it a bit by suggesting that deconditioning could be the cause.

Similarly, in his section on metabolic syndrome and ME/CFS, Theoharides proposes that problems with blood pressure regulation and insulin resistance, “most probably reflect the lack of physical activity and prolonged lack of muscle use in ME/CFS patients”.

low energy production ME/CFS

Theoharides agrees the energy production problems in ME/CFS are real and posits a new cause for them.

But then Theoharides agrees that a hypometabolic state which reduces energy production (ATP) is probably present.  He also agrees that the typical ME/CFS phenotype, i.e. the way the disease presents itself clinically, largely matches that found in people with mitochondrial diseases. He notes that muscle biopsies do show signs of mitochondrial problems.

On the other hand, people with ME/CFS don’t have the mitochondrial DNA mutations, enzyme issues or drops in ATP production typically found in those diseases.

He suggests that free radicals produced by pro-inflammatory cytokines could be whacking the mitochondria in ME/CFS so hard so as to blunt their ATP production, but then notes that no consistent evidence of cytokine upregulation, has been found.

After basically concluding that energy production is a problem in ME/CFS but that none of the usual suspects are the likely answer, and citing the fact that physical, mental and/or emotional stress tends to do people with ME/CFS in, Theoharides, like the Cortene group, turned to the HPA axis.

Many ME/CFS studies, after all, have found problems in the HPA axis – one of the two stress response systems in our bodies – and the axis does affect metabolism. Could it be ground zero for ME/CFS?

Mast Cell Activation

Theoharides thinks so. He proposes that mast cell activation, smack dab in the heart of the HPA axis – the hypothalamus – is occurring in ME/CFS.

If mast cells are involved in ME/CFS it wouldn’t be that much of a surprise.  They are, after all, extraordinarily versatile immune cells which have the capability to produce the extraordinary number of symptoms found in ME/CFS.  Containing hundreds of immune mediators, they can respond to a wide range of stimuli – from pathogens (including mold) to hormones to toxins to immune and neuronal factors.

Best known as mediators of allergic reactions, they’re also “sensors of environmental and psychological stress.” These “sensors” can secrete localized “danger signals” which stimulate the microglia in small pockets of the body/brain.  Theoharides proposes that a mast-cell induced inflammation in the hypothalamus could be causing chronic fatigue syndrome (ME/CFS).

The Mast Cell / Hypothalamus Inflammation Connection

Several studies suggest that inflammation is present in the brains of people with ME/CFS and/or fibromyalgia and Theoharides thinks he knows how this occurs.

It turns out that most of the brain’s histamine is located in the hypothalamus. Plus mast cells are also found in the pituitary gland (as well as the thyroid, the thalamus and the pineal gland).

Theoharides’ mast cell ME/CFS hypothesis begins with a hormone – corticotropin releasing hormone (CRH) – which is released by the hypothalamus during stress and which has been implicated in a series of neuroinflammatory disorders.

hypothalamus chronic fatigue syndrome

Theoharides believes that mast cell activation in the hypothalamus – a key hormone regulator with connections to the limbic system- could play a key role in ME.CFS.

Theoharides believes CRH stimulates the mast cells in the hypothalamus (and elsewhere) to produce something called vascular endothelial growth factor (VEGF), which then increases the permeability of the blood-brain barrier (BBB). That leaky BBB then allows more immune cell (e.g. mast cell) and perhaps pathogen infiltration into the brain and bingo, you have inflammation.

Once in the hypothalamus those activated mast cells produce more CRH, further tweaking the hypothalamus and producing compounds such as histamine, tryptase and mtDNA which send the microglia into a frenzy, causing them to release inflammatory cytokines/chemokines (IL-1B, IL-6, CCL2) that further disrupt hypothalamic functioning.

While the pro-inflammatory cytokines are busy doing that, Theoharides also believes they’re likely whacking the mitochondria in the brain and body, causing centrally (brain induced) as well as peripherally produced (body induced) fatigue, sleep problems, etc.

The main problem, though, is a not an overt threat but hyper-sensitized microglial cells pouring out inflammatory factors in response to the slightest stressors.

(Meanwhile, mast cell activation in the pineal, pituitary and thyroid glands may also be disturbing sleep and producing more fatigue.)

And there you have it. Mast cells – which just happen to be concentrated in several of the brain areas implicated in ME/CFS – have gone off the rails. They’re causing microglial cells to produce pro-inflammatory factors which are producing inflammation in key parts of the brain that are involved in the stress response, fatigue, sleep, etc.

The Hypothalamus – A Central Player

A couple of years ago, though, Dr. Bateman of the Bateman-Horne Center came to a similar conclusion: she believes that inflammation in the lower part of the brain containing the thalamus, hypothalamus and pituitary plays a key role in ME/CFS.  The hypothalamus, which sits just above the brain stem, regulates blood pressure, temperature, and hormone and water content.

Dr. Bateman noted that these organs control the hormones (the hypothalamus is the hormonal control center of the brain) and much of the autonomic nervous system, and then pointed out a long list of hormonal problems (corticotrophin releasing hormone (CRH), growth hormone, thyroid, LH/FSH, vasopressin, oxytocin) that have been uncovered in ME/CFS and fibromyalgia.

She believes that a “limbic encephalitis” is causing a cascade of problems going both ways; up into the cortex and down into the thalamus, pituitary and the autonomic nervous system.

A Mystery No Longer? The Big Picture Emerging In Chronic Fatigue Syndrome? Dr. Bateman Talks

Treatment

Theoharides blasted through several possible mitochondrial enhancing treatments (bezafibrate, angiotensin II inhibitors, CoQ10, Losartan) which he didn’t find all that much promise in, before focusing on magnesium, which he noted plays a “critical role in energy metabolism and in maintaining normal muscle function(ing)”.

Theoharides cited studies indicating that magnesium supplements are able to significantly increase muscle strength and endurance and did so, interestingly enough, by enhancing glucose availability in the brain (possibly low in ME/CFS) and muscles, and by delaying and/or reducing lactate accumulations (possibly high in some people with ME/CFS/FM).

Then it was on to flavonoids, which Theoharides reported have anti-inflammatory, anti-oxidant and neuroprotective effects. Genistein can reduce muscle fatigue while epigallocatechin, naringin and curcumin have been shown to ameliorate ME/CFS symptoms in experimental models.   Astragalus flavonoids, olive extract, and quercetin may have similar effects.

Luteolin was the highlight of the bunch.  With its mast cell inhibiting, anti-oxidant, anti-inflammatory, microglia inhibitory and neuroprotective properties, luteolin is very high on Theoharides’ list, and in 2015 he produced a paper extolling its benefits.  (One study found that tetramethoxyluteolin or methlut appears to be the most effective mast cell inhibiting form of luteolin and is more effective than cromolyn.) Theoharides cited studies that luteolin improved symptoms in autism spectrum disorder (ASD), post-Lyme Syndrome and brain fog in (the not particularly rigorous) open-label trials.

Theoharides has hailed fatigue and mast cell inhibiting properties of flavonoids before and has even produced his own line of supplements, but his statement that, “novel treatment approaches are required to address the central pathogenic processes” in these diseases indicates that, in their current form, these flavonoids are not the answer.

One of the problems has been that it’s hard to get these substances into the brain.  At the end of the paper, though, Theoharides proposes a different way of supplement administration that may be more effective.

Intranasal Administration

“Intranasal administration of select flavonoids may reduce inflammation in the hypothalamus and correct the central pathogenesis of ME/CFS.”

Intranasal administration – basically a shot of volatilized factors into the nose and hopefully eventually into the hypothalamus- is getting more and more attention. Theoharides even suggested if it worked it could even correct the problem.

intranasal spray chronic fatigue syndrome

Theoharides proposes that intranasal sprays may be able to get at the inflammation in the brain

No studies have been done, but since the hypothalamus sits behind the amygdala, which is right behind the nose, it’s possible intranasal supplementation could help dampen down inflammation there.

Flavonoids are just the beginning of the intranasal administration story, though. Over the last couple of years more and more people with ME/CFS/FM have been experimenting with intranasal administration of insulin and glutathione.

Plus, Theoharides mentioned another intranasal option -microvesicle trapped curcumin – that is emerging. Curcumin is perhaps the most scintillating of all the natural anti-inflammatories, but bioavailability has been a challenge.

In 2015 Theoharides proposed that intranasal administration of tetramethoxyluteolin might be useful as well.

A blog on intranasal administration is coming up.

Conclusion

Dr. Theoharides agrees that problems with energy metabolism are likely present in ME/CFS but proposes that their genesis probably lies in mast cell activation in the hypothalamus and other brain organs. Theorharides suggests that corticotropin releasing hormone produced by the hypothalamus activates masts cells to produce substances that activate the microglia, causing the production of pro-inflammatory substances which produce centrally or brain induced fatigue and autonomic nervous system issues. Mast cell activation in the pituitary and thyroid produces further problems with sleep, fatigue and cognition.

Theorharides also proposes that intranasal application of anti-inflammatory substances such as cucurmin and luteolin may be able to access the hypothalamus thus tamping down the neuroinflammation he believes may be at the heart of ME/CFS.

 

 

 

Autoimmune Model Proposes Chronic Fatigue Syndrome (ME/CFS) Begins in the Gut

Jonas Blomberg’s paper “Infection Elicited Autoimmunity and Myalgic Encephalomyelitis/Chronic Fatigue Syndrome: An Explanatory Model” was published in “Frontiers in Immunology”, an apt journal for a paper featuring an “explanatory model” of chronic fatigue syndrome (ME/CFS). Autoimmunity is definitely a new “frontier”; as Blomberg points out, it’s possibility not a reality yet, but like other frontiers it evokes new vistas – new opportunities and some new challenges.

European ME/CFS reseachers

Jonas Blomberg headed up a European group which produced an autoimmune model of ME/CFS

Blomberg has recently been immersed in a study designed to validate (or not) Dr. Scheibenbogen’s autoantibody findings in chronic fatigue syndrome (ME/CFS). The lead role the Europeans are taking on in exploring autoimmunity in ME/CFS is evident: Blomberg and Gottfries are Swedish, Scheibenbogen is German, and Mella and Fluge – of the Rituximab trial – are Norwegian.

(Carl-Gerhard Gottfries’ story is so unusual that it warrants a short retelling. Gottfries, a Swedish psychiatrist, recovered from ME/CFS using, of all things, a staphylococcus vaccine.  Gottfries opened an ME/CFS clinic, published his findings and treated patients with the vaccine for several decades until it was withdrawn from the market. Find out more about Gottfries’ fascinating story here.)

There are so many ideas floating around concerning the cause ME/CFS that one is tempted to throw up one’s hands. Is cellular energy production in the dumps? Are the autonomic nervous system problems keeping people wired and exhausted at the same time? Is an autoimmune process pummeling the body? Are hidden infections tormenting ME/CFS patients with never ending flu-like symptoms? Or as Cortene suggests, are problems in the HPA axis wreaking havoc on the rest of the body.

We could go on and on (ion channel dysfunction (Griffiths University); whacked out basal ganglia (Miller/Japanese); microbiome dysregulation (Lipkin & Hornig, Unutmaz, Lombardi), “traveling genes”  (RCCX – Meglathery); atypical sepsis (Bell); neuroinflammation (Younger), (mast cell activation in the hypothalamus – Theoharides. ).

The fact that so many people have proposed so many interesting hypotheses is encouraging, but the downside to such a munificence of possibilities is a kind of inertia. Until the ME/CFS field settles on one or a few models of disease, this small field is inevitably going to progress more slowly that we would wish.

In fact, the two Davises at Stanford (Ron and Mark – not related) have questioned whether the field should devote time and money to chasing down hypotheses at all.  Better, they have suggested, to gather more and more data and see what emerges. That said, something has been emerging – an explanatory model in which autoimmunity plays a key role.

An Autoimmune Model of Chronic Fatigue Syndrome 

Basically, the authors propose that it all starts with your genes and your leaky gut. Not the leaky gut you necessarily associate with ME/CFS but the leaky gut you had before, perhaps long before you came down with ME/CFS.

A Genetic Predisposition

Autoimmune diseases typically feature a strong genetic component and run in families. It’s not that rheumatoid arthritis shows up in family member after family member. It’s that a range of other autoimmune diseases do. Blomberg picks out three intriguing autoimmune diseases – thyroid disease, Sjogren’s Syndrome (SS) and lupus – which studies suggest run in ME/CFS families.

genetic predisposition to chronic fatigue syndrome

Evidence of a genetic predisposition is one of several factors suggesting ME/CFS could be an autoimmune disease.

ME/CFS itself is also associated with diseases Blomberg considers to be emerging autoimmune diseases including hypothyroidism, fibromyalgia and POTS, each of which has been associated with increased levels of autoantibodies. Blomberg clearly believes an autoimmune cluster containing many of the diseases associated with ME/CFS is emerging before our eyes.

High rates of two of those diseases (thyroid, SS) also recently showed up in a postural orthostatic tachycardia syndrome (POTS) study (along with antiphospholipid syndrome).

Blomberg then ploughed through genetic, immune and epigenetic data in ME/CFS, highlighting some findings suggesting autoimmunity might be present.

For instance, autoimmune diseases often occur when HLA molecules improperly display self-antigens to cytotoxic or helper T-cells.  T-cells, it turns out, are often huge drivers of autoimmunity, and when they produce autoimmunity, HLA issues are often prominent. Guess what: an HLA issue has been found in ME/CFS. (Ron Davis is studying HLA genes in ME/CFS.) Another study found that increased prevalence of genetic alteration (a SNP) in a T-cell receptor gene known to play a role in autoimmunity suggested that a T-cell based autoimmune process could be present.

Infections, EBV, Autoimmunity and ME/CFS

Infections often trigger autoimmunity. In fact, the infectious trigger that has sparked ME/CFS for many is one big clue that an autoimmune process may be present. With regard to autoimmunity, the more severe the infection, the better, and several studies show that deficiencies in IgG subclasses may have left people with ME/CFS more vulnerable to a severe infection.

Several gene expression studies showing alterations in T-cell and innate immune response genes suggested that ME/CFS patients’ immune systems could be fighting off an infection.

The Autoimmune Virus

EBV is especially interesting as a facilitator of autoreactivity. Blomberg et. al.

If you’re unlucky enough to first meet up with the Epstein-Barr virus (a common trigger of ME/CFS) during adolescence, it’s likely to trigger your immune system to produce a massive number of antibodies, including autoantibodies.  EBV also produces antigens with highly repetitive structures (e.g., Gly–Ala–Gly–Ala repeats in EBNA1) which tend to confuse the immune system and trigger the production of autoantibodies.

It’s no wonder, then, that infectious mononucleosis (glandular fever) significantly increases the risk of later coming down with at least two autoimmune diseases: multiple sclerosis (MS) and lupus. That’s an interesting enough intersection for Blomberg to assert that the immune responses that ME/CFS, MS and lupus have to EBV should be compared.

The Key Organ – the Gut

Anyone have gut symptoms (cramping, bloating, loose bowels, constipation) prior to ME/CFS?  I did – they weren’t major, but if one area of my body was a little bit off back then, it was my gut.

Blomberg believes your leaky gut may be the key to your illness. Not the leaky gut you necessarily have now, but the leaky gut you had before you got ME/CFS.

gut chronic fatigue syndrome

Blomberg believes a genetic predisposition and a leaky gut set the stage for ME/CFS

The gut is such a potential hotspot for autoimmunity because it contains so much foreign material. In fact the gut has been posited as something of a training ground for the immune system- it provides the immune system with the foreign materials it needs to learn how to distinguish self from non-self.

Gut disturbances are fairly common in autoimmune diseases, and the idea that alterations in gut flora are touching off autoimmune processes is being examined in a host of autoimmune diseases (multiple sclerosis, type 1 diabetes, RA, ankylosing spondylitis). The common occurrence of irritable bowel syndrome (IBS) – and the leaky gut that often comes with it – in ME/CFS presents a potential pathway for autoimmunity.

Blomberg proposes that the breach of your gut barrier created a state of low level chronic inflammation prior to you getting ME/CFS. The gut barrier is important because it’s a place in the body where tolerance (the ability to distinguish between self and non-self antigens) is more difficult to maintain. Given the extraordinary diversity and sheer number of gut bacteria, it’s easy to see how the immune system could be overwhelmed and lose it’s way.

Blomberg believes that slow leakage from the gut created a population of auto-reactive B-cells that remained mostly inactive or quiescent (in a state of anergy), almost like undercover agents infiltrating a city, waiting for the signal to pounce.  At some point a “decisive” immune event flipped them into action, and an autoimmune disease – ME/CFS – was born.

He bases his hypothesis of pathogenic autoantibody creation in ME/CFS on a process that appears to be occurring in lupus. The first step occurs when a genetically predisposed person meets up with bad gut bacteria. First, abnormal but not pathogenic B-cells, which have a “weak autospecificity”, appear. These weakly targeted B-cells are not strongly directed against a specific antigen or part of the cell and don’t appear to be particularly dangerous at first, but the body should still eliminate them. Blomberg proposes that it doesn’t.

Over time exposure to the bad gut bacteria causes the specificity of the B-cells to change – making them more targeted and dangerous. At some point an infection turns them on and they start producing clones of themselves which begin attacking the body. ME/CFS is born.

One possible sign that tolerance – the ability of the body to remove autoantibody-producing cells  – has been breached in ME/CFS are the TFG-B (and IL-10) findings. IL-10 and TGF-B, in particular, are the rare cytokines that are more or less consistently found dysregulated in ME/CFS cytokine studies. It turns out that T-helper cells use both these cytokines to regulate tolerance and anergy at the gut mucosa – the very place Blomberg believes the process of autoimmunity in ME/CFS begins.

Ian Lipkin’s recent study found a significant difference in gut composition between ME/CFS patients with IBS and those without. Some of those differences appeared to affect energy production.

Autoantibodies

It turns out that autoantibodies by themselves are not necessarily indicative of autoimmunity. Some “natural autoantibodies – (mostly IgM antibodies) are simply designed to rid the body of dead/apoptotic, damaged and infected cells and rarely cause autoimmune diseases. Other more dangerous autoantibodies need to be turned on by “cell danger” signals before they do harm. (This is why autoantibodies can often be found in healthy people.)

Autoantibodies have, of course, been found in ME/CFS and related diseases like POTS. At the Montreal conference Blomberg reported that his team was validating Scheibenbogen’s autoantibody findings in ME/CFS. They are one clue that autoimmunity is happening in ME/CFS but they provide, Blomberg reported, only circumstantial evidence of autoimmunity.

It’s the “erroneously activated” B-cells, he reported, that are “the root of the evil”, and it’s these cells that need more focus. Blomberg asserts that an in-depth sequencing of these deranged B-cells is needed. By sequencing the variable immunoglobulin chains found in them it should be possible to trace back to how they turned bad.

Other Possible Evidence of Autoimmunity

As noted earlier, Carl-Gerhard Gottfries successfully used a staphylococcal vaccine for years to treat himself and others with chronic fatigue syndrome (ME/CFS). That approach may have worked because the immune stimulation it provoked may have been able to induce tolerance; i.e. induce the body to remove the bad B-cells.

Since Rituximab knocks down B-cells, thereby removing misbehaving ones, it would seem to fit into Blomberg’s hypothesis. Unfortunately, the Rituximab trial failed, and if anecdotal reports are correct, more completely than we could have imagined.

Another possible indication that autoimmunity is present in ME/CFS are studies suggesting the incidence of Hodgkin’s lymphoma is increased in ME/CFS as it is in other autoimmune diseases.

In the end, though, Blomberg reports that the evidence that autoimmunity is at work in ME/CFS is circumstantial. It relies on the fact that people with ME/CFS often have other autoimmune diseases such as thyroiditis or diseases suspected of involving autoimmunity such as POTS, FM and IBS, that autoantibodies are present, and that immunostimulation (IVIG, staphyloccocus vaccine) may work.

Most of the work, though, needed to fulfill the Witebsky–Rose criteria for autoimmunity, remains to be done.

Primary Biliary Cirrhosis – An Autoimmune Roadmap for Chronic Fatigue Syndrome (ME/CFS)?

At the start of their paper, Blomberg et. al. proposed that their model could explain many of the facets of ME/CFS that have emerged – the most prominent of which are the energy production problems.

An autoimmune disease exists in which an attack on the energy producing processes in the body produces symptoms and findings similar to those found in ME/CFS.  In primary biliary cirrhosis  (PBC) antibodies attack a small fatty acid molecule (lipoic acid) that’s part of the energy producing machinery on the surface of the mitochondria.

pyruvate dehydrogenase

Pyruvate Dehydrogenase -By Jonathanmott09 – Own work, CC BY-SA 3.0, https://commons.wikimedia.org/w/index.php?curid=18520937

The antibodies in PBC attack the pyruvate dehydrogenase (PDH) enzyme complex which regulates the transition from glycolysis (anaerobic energy metabolism) to the tricarboxylic acid cycle (aerobic energy metabolism). The same issue -the transition from glycolysis to aerobic metabolism – has shown up repeatedly in ME/CFS studies.

Even though PBC is considered a liver disease, it produces enormous amounts of fatigue as well as cognitive problems, orthostatic intolerance and sympathetic nervous system hyperactivity. In fact, Julia Newton, who studied PBC before she studied ME/CFS and started a Rituximab trial in PBC two years ago, stated back in 2013 that,

“…at this stage the muscle and cardiac abnormalities that we have seen in patients with ME/CFS are exactly the same as those that we have seen in patients with PBC.”

Another fascinating aspect of PBC is that the autoantibodies are attacking a molecule, lipoic acid, which is added to the PDH enzyme using a rare process called lipoylation. Because some gut bacteria (Novosphingobium) also use lipoylation, it’s possible that bacterial leakage initiated the autoimmune process causing PBC.

Blomberg suggested that pathogenic, as yet unidentified immunoglobulins directed against mitochondrial proteins could be the source of ME/CFS and exhorted researchers to compare the post-exertional malaise in ME/CFS to other diseases such as fibromyalgia, PBC, etc.

Autoimmunity or Oxidative Stress? 

Finally Blomberg et. al. suggested that oxidative stress could be producing the same energy depleting issues as autoimmunity. That’s an intriguing idea given the comforting consistency oxidative stress study results have had in ME/CFS.  The authors noted that it was recently shown that the oxidation of a critical part of the pyruvate kinase enzyme can effectively block the transition of glycolysis to aerobic metabolism.

Dr. Shungu believes the lactate accumulations and glutathione reductions his studies have validated in the ventricles of the brains of ME/CFS patients are associated with oxidative stress.

Conclusion

Blomberg’s autoimmune model proposes that the seeds for ME/CFS were lain possibly long before the disease appeared and only “sprouted” once a decisive immune event occurred. He believes that a genetic predisposition plus a leaky gut laid the groundwork over time for what eventually became an autoimmune disease.

Autoantibodies provide circumstantial evidence of autoimmunity in ME/CFS but are not nearly enough to validate it.  Blomberg asserted that an intensive study of the abnormal B-cells in ME/CFS could both help to validate that diagnosis and identify the precipitating event which triggered this illness.

If ME/CFS is an autoimmune disease targeting the mitochondria it may have a close cousin called primary biliary cirrhosis (PBC) which produces similar symptoms including enormous fatigue. In PBC autoantibodies disrupt the transition from anaerobic to aerobic energy production – the same process, interestingly enough, that appears to be affected in ME/CFS.

While autoimmune processes could produce the energy problems in ME/CFS, oxidative stress – which studies have found to be consistently high in this disease – could produce the same result.