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ME/CFS Seahorse Energy Production Study Shows Surprises

Dr. Maureen Hanson leads one of the three NIH funded ME/CFS research centers, but her ME/CFS research doesn’t stop there.  Using samples from Dr. Daniel Peterson provided by the Simmaron Research Foundation, she’s also been assessing the metabolism of one of the most important cells in our immune systems: our T-cells.

T-cells affect a large part of our adaptive immune response that clears out infections. They do this by regulating our immune response (CD-4 or Helper T-cells) and/or by killing off pathogens that have infected other cells (CD-8 or cytotoxic T-cells).

Hanson and Mandarano and Seahorse machine

Maureen Hanson, Alexandra Mandarano and the Seahorse machine

Prior to getting activated, T-cells are primarily on sentry duty.  Once activated by dendritic cells presenting little bits of pathogens to them things change dramatically, however. The T-cells rev up their cellular engines to order to start pumping out cytokines or clones en masse in order to stop the infection. Both parts of energy production – glycolysis and oxidative phosphorylation –  have to jump into action.

In short, assessing the energy production of activated T-cells is a perfect way to determine if their energy metabolism has been affected in ME/CFS – and that’s just what Maureen Hanson’s group did.

Alexandra Mandarano, a graduate student in Hanson’s lab, took T-cells from 53 healthy controls and 45 pretty long duration (avg. a@ 12.7 years) ME/CFS patients and healthy controls and tricked them into going into high alert with antibodies plus IL-2. Then, using the Seahorse Flux Analyzer, she examined how well the two parts of their cellular energy production system did in both unactivated and activated T-cells:  glycolysis – the anaerobic part which takes place outside the mitochondria, and oxidative phosphorylation – the aerobic part which takes place inside the mitochondria (and produces far more ATP) .

Dr. Hanson presented on her results at the recent Open Medicine Foundation sponsored Harvard Symposium


Whether they were activated or not, mitochondrial energy production; i.e. oxidative phosphorylation (the main ATP producer) was normal for both the CD4 and CD8 cells in the ME/CFS group. When pushed, the mitochondria in the ME/CFS patients’ cells quickly got energy production up to speed. That was a surprise. Usually when you push a cell or system in ME/CFS it fails- but, in this case, the T-cells responded normally.

Then came the real surprise.  Systems in ME/CFS often test out fine or at least not strongly abnormal at baseline or rest, but in this case Hanson found low glycolysis activity in both the T-helper cells (CD4) and the CD8 cells at baseline.  Simply prowling around the body, they had considerably lower levels of glycolytic activity.  When pushed, though, their glycolytic activity was normal.  The pattern was opposite to what we usually see.

That wasn’t all. It’s possible with the Seahorse to turn off different energy production pathways in order to assess how effectively the other pathways are at compensating.  When the oxidative phosphorylation pathways were turned off experimentally, the ME/CFS patients’ glycolytic pathways failed to compensate as effectively as did those of healthy controls.

Mandarano did not find problems with mitochondrial ATP production but did find issues with glycolysis

Thus no problems with mitochondrial energy production were found but three potential issues with glycolysis popped up: low glycolytic activity in both forms of unactivated T-cells, and poor glycolytic compensation with the oxidative phosphorylation pathways were turned off.

Hanson’s group next examined a critical part of energy production called the mitochondrial membrane potential. Our mitochondria need to maintain a certain membrane potential to keep up the flow of positively charged ions into the mitochondria. It does this by keeping more positively charged ions outside of the mitochondria and more negatively charged ions inside the mitochondria. Her group used a flow cytometer to assess the levels of mitochondria present and to determine how strong the membrane potential was.

The mass and membrane potential of the ME/CFS patients’ CD4 T-cells and the mitochondrial mass of the CD8 cells was normal, but the membrane potential of the CD8 T-cells – whether activated or not – were significantly impaired in the ME/CFS patients.

Four potential problems, then, were found:

  • low glycolytic activity in unactivated CD4 and CD8 T-cells
  • poor glycolytic compensation when the oxidative phosphorylation pathways were turned off
  • The mitochondrial membrane potential was impaired in the CD8 T-cells

Dr. Hanson left her presentation with the  encouraging statement that we are starting to put the pieces of the puzzle together in ME/CFS and the tantalizing suggestion that ME/CFS might be something different than what we think it is right now; i.e. keep an open mind, don’t put all your eggs in one basket, and be prepared for surprises.


Hanson and her co-authors have submitted a paper and we will get more details when their paper is published but, with these preliminary results, we have a few more data points on cellular energy production in ME/CFS. While noting that several study results are pending, maybe it’s time for a look at what we have.

It should be noted that measuring energy production is very complex. Different researchers are doing it in different ways, and I am no judge of any of them.  Researchers are using different instruments, different criteria, different kinds and numbers of patients, and they are reporting things differently. Solving those problems is one of the reasons for the NIH funded ME/CFS research centers where larger studies can use proven technologies and rigorously defined patient populations.

Check out some of the different protocols which have assessed mitochondrial functioning in isolation from the blood in ME/CFS:

Study protocols

  • Hanson’s group activated her T-cells using antibodies and IL-2 and then tested activated and unactivated cells in the Seahorse Machine
  • Tomas took PBMC’s and stressed them in the Seahorse machine
  • Stanford took PBMC’s and then used laboratory assays to test each of the complexes and flow cytometry to assess mitochondrial membrane potential
  • Fisher (unpublished) appears to have taken PBMC’s and stressed them in the Seahorse machine
  • Vermeulen measured ATP PBMC’s etc. in the lab
  • Smits measured ATP production rate in muscle biopsies

The Land of Mixed Signals

We seem to find ourselves in a familiar place – the land of mixed signals! One encouraging unmixed signal is that everyone seems to be finding something wrong – just often different things.


Mitochondria Mass – Normal

  • Hanson – CD4 and CD8 (T-helper cells)
  • Fisher

Mitochondria ATP production – Normal

  • Hanson (T-cells)
  • Stanford study (not a Ron Davis study) (PBMC’s)
  • Fisher (PBMC’s)
  • Vermoulen (PBMC’s)
  • Smits (muscle biopsy)

Increased ATP Production Overall

  • Stanford
  • Preliminary results from NIH Intramural study

Reduced ATP production

  • Tomas – under both low and high glucose conditions

Functioning of Complexes – Normal

  • Stanford (I-IV)
  • Vermeulen (I-II)

Functioning of Complex V – reduced

  • Fisher

Increased Glycolysis at Baseline (PBMC’s)

  • Stanford

Reduced Glycolysis at Baseline (T-cells)

  • Hanson

Reduced Glycolysis (low glucose conditions)

  • Tomas

Reduced Compensatory Glycolysis

  • Hanson
  • Tomas (?)

Glycolysis Stress Test (Glycolysis, glycolytic reserve, glycolytic capacity)- normal

  • Tomas
  • Fisher

It’s quite a muddle.  Surprisingly, though, the most consistent finding thus far is normal (or in two cases) increased mitochondrial production (!) Not many studies have directly measured glycolysis, but in these early days the results are mixed.


cells in the blood

The most consistent result so far is normal (or increased) mitochondrial function but none of the above studies tested cells in the blood – where an inhibiting factor may lurk. (Seahorse machine cannot test cells in the blood.)

Note that all these studies are assessing the energy production of the mitochondria in isolation. None tested cells in the blood where Davis, Fluge and Mella and Prushty have found evidence that some sort of inhibiting factor may be present. The metabolomic findings which suggest problems with glycolysis are present have been assessing factors in the blood and urine as well.

Adding an exercise stress test would, of course, add another important factor. At the NIH ME/CFS Conference, Brian Walitt reported that the NIH is finding that exercise causes mitochondrial oxygen consumption (ATP production) to increase in the healthy controls but to decrease in about half of the ME/CFS patients. Several recent studies have validated that exercise impairs energy production in ME/CFS (blog coming up). Where and how the energy depletions are occurring is unclear. (Note that most of these studies examined immune cells not muscle cells.)

We obviously have long way to go to fit all the different pieces of the energy production puzzle in ME/CFS together but the good news is that an increasing amount of research is now being aimed at deciphering what’s inhibiting energy production in this disease.

The Simmaron Research Foundation’s collaboration with Maureen Hanson – which paired rigorously diagnosed patients with a respected researcher –  is just one way the Foundation is contributing to solving that puzzle.

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  • Dana Tigani

    August 28, 2019 at 6:31 pm - Reply

    Excellent article Cort. It’s just so ironic that I hated teaching this stuff and now it’s at the forefront of ME/CFS research.

  • Lilpink

    August 28, 2019 at 7:47 pm - Reply

    Maybe it would be less of ‘a muddle’ if all centres used the same, and the strictest, criteria, ie ICC. I believe Hanson does use ICC. Gold star to her for doing so.

  • Cort Johnson

    August 28, 2019 at 9:43 pm - Reply

    Ha! You never know what will come around…

  • Cort Johnson

    August 28, 2019 at 9:44 pm - Reply

    She has a reputation for being quite rigorous. I think we can trust anything coming out of her lab.

  • Brenda

    August 28, 2019 at 10:39 pm - Reply

    Not sure if this is interrelated or not, but I recently saw something online about some FMS patients having less pain when put on the drug metformin suggesting glucose metabolism and/or insulin sensitivity is at play for some patients. (I have FMS with extreme fatigue especially post exertion)

  • Aidan

    August 28, 2019 at 11:10 pm - Reply

    I wonder if insulinoma is being missed in the pancreas Benign types???

  • ElizabethKay

    August 28, 2019 at 11:18 pm - Reply

    While we’re touching on the practice of using ICC as the litmus test for ME/CFS — which I was really impressed to learn of — how long has the ICC been the litmus test for ME? When, more or less, did the earlier adopters of this start this?

  • ElizabethKay

    August 28, 2019 at 11:24 pm - Reply

    P.S. My family members still think this fatigue, and flare ups, and crashes — are all in one’s head! I’ve even been to physical therapists who say it’s all in my head. What a shame!

  • Cort Johnson

    August 28, 2019 at 11:55 pm - Reply

    It may very well be related! Check out this blog on metformin and fibromyalgia from Health Rising:

    Fibromyalgia, Pre-Diabetes and Metformin: Could a Diabetes Drug Help with FM (and ME/CFS?)

  • Cort Johnson

    August 28, 2019 at 11:57 pm - Reply

    I don’t know but it seems like its been several years – at least 3 or 4 – that either the CCC or ICC has been regularly used. The NIH explicitly began allowing these definition criteria to be used in its studies several years ago.

  • Kate

    August 29, 2019 at 3:43 am - Reply

    Elizabeth, I can’t address your family’s lack of support but I can share that I had a similar experience with my family. It isn’t unusual in this patient population because of the decades long smear campaign.
    I’m sorry for those experiences you’ve had, it is so terribly painful.

    I can tell you how I finally learned to deal with medical personnel who are ignorant and unwilling to listen or be educated. Ive had more than one literally roll their eyes….and that’s when I get up and walk out and let my insurance company know that I cancelled the appointment due to lack of necessary competence in re my medical condition.

    I’m willing to share information if they are willing to listen… because they don’t know what they don’t know…but no one need tolerate medical abuse or disrespect, and no one with ME can afford to waste precious and few drops of time and energy on those suffering from refractory ignorance.

  • Moira

    August 29, 2019 at 9:05 am - Reply

    Cort, very interesting!! I haven’t watched the presentation and was wondering if Serine was mentioned? Impaired glycolysis and reduced membrane potential in this study. Add mitochondrial fragmentation and redox imbalance from other studies. Then the common thread seems to be Serine deprivation????? See:

  • Learner1

    August 29, 2019 at 1:33 pm - Reply

    This is a muddle. Your point about the mitochondria being measured in isolation is a good one. We patients have mitochondria not in isolation and have to live with them.

    I have had mitochondrial function testing done, which showed greatly impaired complex I, and complexes II-IV spewing out large amounts of free radicals, with low mito content at first, going higher after 9 months of intervention.. A noted researcher told me my low lactate is due to impaired glycolysis. I’d like to know more about how to fix these.

    Though what these researchers are doing is interesting, it would be a lot more interesting if their findings had applicability for ME/CFS patients. I suspect any mitochondrial abnormalities are in response to Bob Naviaux’s list of cell dangers, which may differ between patient, hence the variation in results.

  • Aidan

    August 29, 2019 at 5:27 pm - Reply

    GSD Glycogen Storage Disease is what she is likely referring to now, they know what this is but have not yet Published the work

  • MKay

    August 29, 2019 at 8:51 pm - Reply

    Do you need some test volunteer’s? Anything would be an improvement for me.

  • Cort Johnson

    August 29, 2019 at 9:59 pm - Reply

    I don’t remember it but it was a pretty short presentation

  • Cort Johnson

    August 29, 2019 at 10:00 pm - Reply

    Interesting! I’m sure there are going to be some really subsets and it sounds like you are in one of them.

  • Colleen Steckel

    August 30, 2019 at 7:31 pm - Reply

    In regards to the ICC (International Consensus Criteria) question. It was published in 2011 and the IC Primer in 2012. I don’t think it was long before some researchers recognized how useful it was for good science. Obviously, the best science has the fewest variables. Making sure that the patients studied are as alike as possible is vital to good science.

    This study from 2016 used ICC patients – A Preliminary Comparative Assessment of the Role of CD8+ T Cells in Chronic Fatigue Syndrome/Myalgic Encephalomyelitis and Multiple Sclerosis “

    It is important to note that the labels used are not reliable. This study labeled CFS/ME used ICC. But other studies using similar label or ME/CFS or CFS or ME may or may not use the ICC.

    Any study that has been done that used Oxford or Fukuda cannot be relied upon to be applicable for those who have ME as per the CCC or ICC (or the original description by Ramsay).

    For those not familiar with the ICC, here is an easy to use Questionnaire. Checking off the boxes for any criteria is only the first step. The IC Primer has information for ruling out other diseases. Useful for all patients whether they fit the criteria, fit the atypical ME criteria or any of the similar diseases that can be confused with ME.

    Too often we have seen patients who ended up having other diseases, getting treatments and fully recovering. It’s very important those patients who are studied have the disease we want studied.

  • Monne

    August 30, 2019 at 9:29 pm - Reply

    I’ve been using transdermal metformin for a couple of months now – definite reduction in all over body pain and much better exercise tolerance, both during and after.
    I wonder if this is another function of the aryl hydrocarbon receptor.

  • Lilpink

    September 1, 2019 at 2:15 pm - Reply

    Thanks Colleen Steckel. That’s very useful information for those not au fait with criteria considerations. Much obliged.

  • Brian Schulz

    September 25, 2019 at 12:42 pm - Reply

    A couple of quick observations. It’s my understanding that mitochondrial disruptions can be very heteroplasmic, meaning that different cell types have different concentrations of abnormal DNA and thus functional impairments. T cells are an easy target but possibly not indicative of overall mitochondrial health. Also, not all mitochondrial disease result in the significant respiratory chain impairments (lowered ATP outlet combined with a rise in lactate and ammonia), sometimes ATP output is only mildly affected but the mitochondria are producing massive amounts of free radicals. I also wonder if mitochondria is the right place to be looking? Personally, my symptoms don’t really kick in until the point where my body should start using fatty acids as a fuel source. This makes me wonder about beta oxidation in people with chronic fatigue and recent findings suggesting issues with AMPK pathways. I’m not a scientist so I really can’t evaluate, but those are a few of the things that pop into my head.

  • Thomas

    January 8, 2020 at 11:05 am - Reply

    If glycolysis was the root cause then ketogenic diet should cure ME/CFS. Reality check: Keto gives relief for many patients but certainly does not cure the condition (been keto for a year myself and know many other patients with ME/CFS on keto).

    I appreciate the research, but maybe we are looking at a symptom and not a root cause here?