All posts by Cort Johnson

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

Results

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.

Overview

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

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
GLYCOLYSIS

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.

Isolation

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.

The First ME/CFS Fecal Transplant Study Suggests the Treatment Holds Promise

Finally a (chronic fatigue syndrome) ME/CFS fecal transplant study. It’s long past due (Maybe way, way long past due –  the Chinese pioneered fecal transplants 2000 years ago but used a cruder method in people dying of diarrhrea – drinking them.)

This first stab at a fecal transplant study isn’t a big statistically rigorous, randomized, placebo-controlled trial. Far from it; it’s more a series of case reports from a physician’s practice over time with a smattering of statistics. It does give us, though, our first data -in rather vivid detail – on the possible efficacy of fecal transplants in ME/CFS.

gut lumen diagram

The gut lumen – from “Does the microbiome an virome-contribute to ME/CFS.-Clin-Sci. March 2018

Ten studies now indicate that the bloom is off in the gut flora of people with ME/CFS. With a 2018 review taking ME/CFS researchers to task for the usual suspects: lack of standardization in patient selection, sample processing, genome sequencing and data analysis, it’s not clear what has gone wrong.

As papers just pour out implicating the gut flora in a wide range of diseases the question becomes more and more what to do about it.  While pre and probiotics can help, it’s possible that fecal transplants – the direct transfer of stool (or portions of the stool) from a healthy person into the gut of an ill person –  may provide a larger, more lasting impact.

The Study

Dr. Julian Kenyon runs The Dove Clinic for Integrated Medicine, in the U.K.  which uses both an oral (pre and probiotics, diet, etc.) and fecal transplant approach to gut improvement.  In this study  – A Retrospective Outcome Study of 42 Patients with Chronic Fatigue Syndrome, 30 of Whom had Irritable Bowel Syndrome. Half were treated with oral approaches, and half were treated with Faecal Microbiome Transplantation – he compared the results of the two.

Kenyon divided his patients into two groups of 21; one was treated with nutritional remedies, probiotics, prebiotics, and dietary and lifestyle advice. The second group, most of whom had failed the first treatment approach, were given 10 fecal implants over ten days.

As seventy percent of the group also had irritable bowel syndrome (IBS) this may have been a more gut impacted group. In an effort to deliver a maximum diversity of flora, each of the implants came from a different, “carefully screened” donor.

The Taymount Laboratory provided the implants. The laboratory runs a 10-day gut flora transplant (FMT) program which starts off with a colon cleanse and includes dietary advice.

While it’s not possible to test donors for all possible pathogens (some of which may be undetectable), the donors’ blood was screened for the following pathogens: Human Immunodeficiency Virus (HIV) 1/2, Hepatitis A. IgM, Hepatitis B (HBsAg), Hepatitis C antibody, Syphilis, IgG/IgM, Full Blood Count, Urea and Electrolytes, Ferritin, C-Reactive Protein, Tissue Transglutaminase, CMV, H-Pylori.

Their stool samples were screened for: Campylobacter (Jejuni, Coli and Upsalliensis), Clostridium Difficile (A/B), Salmonella, Yersinia Enterocolitica, Vibrio (Parahaemolyticus Vulnificus and Cholera), Diarrhoea-causing E-Coli/Shigella, Enteroaggregative E-Coli (EAC), Enteropathogenic E-Coli (EPEC), Enterotoxigenic E-Coli (ETEC), Shiga-like toxin-producing E-Coli (STEC), E-Coli 0157, Shigella/Enteroinvasive E-Coli (EIEC), Cryptosporidium, Cyclospora Cayetanesis, Entamoeba Hystolitica, Giardiolambia, Adenovirus, Astrovirus, Norovirus GI/GLL, Rotavirusa, Sapovirus.

The Taymount Laboratory website reports that there’s no documented evidence  infections being passed via fecal transplants. As of this month, though, that’s no longer true. The FDA recently reported on two multi-drug resistant infections passed via fecal transplants.

Different kinds of transplant techniques are used. Some clinics use a tube to insert the transplant through the esophagus and into the stomach or the duodenum. This clinic uses a rectal catheter to deliver the goodies into the large bowel or colon. Others use something called a colonoscope.  Some companies are creating pills that can be swallowed.

Results

The study reported on past patient outcomes (retrospective case-control) using a vague metric indeed, “% improvement”, to assess results. While the statistics were crude, the data presented – in short statements describing how the patients improved or didn’t improve – provided vivid reading indeed.

The statistics (Mann-Whitney test of “% improvement:  U=111.5, p=.003) indicated dramatically increased improvements in the fecal transplant group compared to the “oral” (probiotic, nutritional supplements, etc.) group.

The Fecal Transplant Group

As noted above the fecal transplant group were tough cases: they hadn’t responded to Dr. Kenyon’s normal treatment regiment of supplements, pre and pro-biotics etc.

Dr. Kenyon’s data suggested that little grey area existed:  the fecal transplants either hit or missed: when they hit, they tended to work quite well; when they missed, they pretty much missed entirely.

In quite a few cases, the transplants were associated with some striking increases in energy. Kenyon reported that the energy levels of 7 of the fecal transplant group returned to normal, practically normal or almost normal. (In one case she simply said “chronic fatigue syndrome resolved”.)

The increases in energy did not come in the newly ill either. Six people who’d had ME/CFS “for many years” either totally recovered or were dramatically improved. One 66 year old person who apparently got ill following an amoebiasis infection in the Himalayas over 30 years ago returned to normal health.

The energy levels of six others were “significantly improved”, “much improved”, “improved dramatically” or “consistently improved”.

In a few cases, it was impossible to determine if improvements in energy had occurred. For instance, Dr. Kenyon reported that the gut problems of a person with severe vaginal thrush, recurrent abdominal bloating, IBS and ME/CFS largely disappeared but didn’t assess her energy levels.  The same occurred with another person with IBS: their IBS disappeared but we weren’t told if her energy levels improved as well.

Four people (@20%)  were either unable to tolerate the implants (n=2) or showed no improvement (n=2).

Table 1. Chronic Fatigue Syndrome Patients treated with FMT

Patient: %Improved
(F)Age 36 Severe Chronic Fatigue Syndrome with Irritable Bowel Syndrome for three years, following multiple antibiotics for Quinsy. Severe debilitating Irritable Bowel, with lack of energy. She had FMT in February 2018, following this the Irritable Bowel cleared up, energy significantly better. Has always had many food sensitivities, they are gradually beginning to resolve. A further course of FMT is under consideration. 70%
(F)Age 40 Polycystic Ovary Syndrome, also Irritable Bowel and a Chronic Fatigue. She had FMT in October 2017, following the FMT her energy is much improved and is practically normal, has remained so ever since. Also, her mood is more stable. 90%
(F)Age 59 Severe Vaginal Thrush for five years, recurrent abdominal bloating, Irritable Bowel Syndrome and Chronic Fatigue Syndrome. Clostridium Difficile in 2013. She had FMT in May 2017, two months after FMT the Irritable Bowel cleared up completely, her skin is significantly better than it was prior to treatment, Vaginal Thrush is still something of a problem, but not as bad as it was. She finds she is no longer craving sweet foods. 90%
(F)Age 73 History over many years of Irritable Bowel Syndrome and Chronic Fatigue Syndrome, also overweight. We treated her with FMT in December 2017, the Irritable Bowel Syndrome cleared up during the two months following the FMT and has remained normal. She is still having difficulty in losing weight. 60%
(F)Age 43 Several years history of Chronic Fatigue Syndrome. Also, Irritable Bowel Syndrome. We carried out FMT in January 2017, since that time the IBS has cleared up, energy significantly improved and has remained so. 70%
(F)Age 42 8-year history of Chronic Fatigue Syndrome. Also, Irritable Bowel Syndrome. We treated her with FMT in November 2018, I first saw her in May 2018. Since the FMT her persistent Oral Thrush has cleared, her digestion has improved, and the Irritable Bowel has settled down. She is no longer constipated. Her energy improved almost to normal following the FMT but has had a bit of a relapse since significant family upset, which has been draining on her energy reserves. 95%
(F)Age 73 Insomnia, persistent Nausea, poor energy due to Chronic Fatigue Syndrome, lack of appetite. Has lost a great deal of weight over several years. Complains of bad body odour. We carried out FMT in February 2017. Since then the Nausea has disappeared, the appetite has returned, and she is now putting on weight. 95%
(F)Age 46 I first saw her in 2016 with a history of Chronic Fatigue Syndrome and Fibromyalgia for several years. We carried out FMT in January 2017, no significant response to the FMT. We are thinking of repeating the FMT. 0%
(F)Age 66 At the age of 26 this patient contracted amoebiasis in the Himalayas, then she had lots of antibiotics for various indications and has had Irritable Bowel Syndrome and Chronic Fatigue Syndrome since the age of 30. Also, she has been diagnosed with SIBO and had developed multiple food sensitivities. We carried out FMT in July 2017, her Irritable Bowel Syndrome normalised over the next four weeks, her energy improved and became normal, then she had exposure to contaminated water, probably containing parasites, then she relapsed to some extent and had to have a second course of FMT in December 2017. Since that time, she has been completely normal. 95%
(F)Age 47 This patient has had regular courses of antibiotics since the age of 12 for a range of reasons. She has had many years of Chronic Fatigue and Irritable Bowel Syndrome. We carried out FMT in August 2018, since then the Irritable Bowel has settled down and the Chronic Fatigue has resolved. 90%
(F)Age 73 This patient has had a history of recurrent Candidiasis over many years, including Oral Thrush. She has many years history of Irritable Bowel Syndrome and Chronic Fatigue Syndrome. We carried out FMT on her in November 2018. Since that time, she has had no more Candidiasis, the Irritable Bowel has settled down, and there is significant maintained improvement in her energy levels. 85%
(F)Age 70 This patient has had a history over many decades of a Chronic Fatigue Syndrome. We used FMT in April 2017, there was no improvement in her energy levels since the FMT. 0%
(F)Age 70 Chronic Fatigue Syndrome for 20 years, also Addison’s Disease, Fibromyalgia and Irritable Bowel Syndrome. FMT carried out in August 2018. She reacted to several of the Implants with Diarrhoea, so we had to stop the Implants. Clinically, no change. 0%
(F)Age 61 20-year history of Chronic Fatigue Syndrome and Fibromyalgia, also Irritable Bowel Syndrome. Oral treatment did not work. FMT was carried out in April 2018. Following FMT her energy improved dramatically and has remained improved. The Irritable Bowel Syndrome has cleared up and she also lost one and a half stone in weight. 90%
(F)Age 41 Many years history of Chronic Fatigue Syndrome, multiple food sensitivities and Irritable Bowel Syndrome. FMT carried out in September 2018. She managed to tolerate half of the Implants and then temporarily had to stop. No clinical improvement yet. 0%
(F)Age 44 Eight-year history of Chronic Fatigue Syndrome getting significantly worse. Also, Irritable Bowel Syndrome. We carried out FMT on her in October 2018. Her Irritable Bowel Syndrome has cleared up completely, energy is beginning to recover. 75%
(F)Age 56 History of Chronic Fatigue Syndrome, Irritable Bowel Syndrome for many years. Resistant to oral approaches for treating both of these conditions. We carried out FMT in May 2018. Since that time her energy is significantly better, and remains better, bowel function is now normal. 80%
(F)Age 70 Chronic Fatigue Syndrome for many years, also Irritable Bowel Syndrome. We treated her with FMT in October 2017. Bowel habit is now normal, resistance to intercurrent infections has now returned to normal, energy was consistently improved and remains so. 95%
(M)Age 65 Chronic Fatigue Syndrome for many years. We treated him with FMT in November 2017. Energy has returned to normal. 95%
(F)Age 52 This patient has had Chronic Fatigue Syndrome for many years. Also, Irritable Bowel Syndrome. We treated her with FMT in July 2018. Since then, her energy has returned to normal and she has now been able to return to work, her gut has also returned to normal. 95%
(F)Age 48 History of Chronic Fatigue Syndrome and Irritable Bowel for many years. We carried out FMT on her in March 2018. Since then her Irritable Bowel Syndrome has cleared up completely and also her energy has returned to normal. 95%

 

The Standard or Oral Approach Group

The other group treated with nutritional remedies, probiotics, prebiotics, and dietary and lifestyle advice generally did improve – but not nearly to the extent that the fecal transplant group did.

Dr. Kenyon reported that most had improved by 30-40% (N=10), two people – one who had had ME/CFS for decades but improved rapidly on Dr. Kenyon’s regimen – improved by 90%, two by 50-75% and the rest with lesser improvements.

Dr. Kenyon, not surprisingly, concluded that fecal transplants are more effective at repairing gut flora than pre and probiotics. While two people responded poorly to the transplants, Kenyon reported they generally provide a safe and potentially effective approach to ME/CFS.

Fecal Transplants

That begs the question – just exactly what is a fecal transplant? It turns out that a variety of transplants are done. Some transplants transfer all the fecal matter while others filter out other components and only transfer the bacteria.

The Taymount Clinic reported that they implant only bacterial matter.  People who go the home route obviously transfer everything: get poop from a healthy donor, and then use saline solution and an enema to get the poop in (which they hold for as long as possible).

As might be imagined raw fecal matter contains all sorts of substances of which  bacteria make up just one component. Generally about 75% water and 25% solid matter, bacteria make up between 25-55% of the solid matter and 6-13% of the total matter. That’s a lot of bacteria – approximately one hundred billion per gram of wet stool – although only  3.0%–6.6% of total fecal matter may be composed of viable bacteria.

Some History

Other components found in fecal matter include significant numbers of epithelial cells that have flaked off the colon (colonocytes), single-celled organisms call archeae and other primitive organisms, viruses, fungi and metabolites.

Clostridium difficile

A Clostridium difficile outbreak in the U.S. caused doctors to search for alternative treatments

In the U.S.. fecal transplants have mostly been used to battle life-threatening Clostridium difficile infections. Transplants got a boost in early 2000’s after a particularly virulent form of C. difficile hit the U.S., causing gastroenterologists and patients to scramble for more effective treatments.  Six hundred and twenty-five thousand C. difficile cases are believed to occur in the U.S and Europe every year.

One women’s unstoppable C. difficile infection prompted her gastroenterologist to tell her, after seven months, to get her affairs in order. She ended up using her daughter as a donor in 2014. She reported:

“My gut drank up the infusion as if it were dying of thirst. My colon, after five months of near-constant spasms, recovered in one transformative instant. Overnight, I went from having 30 bowel movements a day to having one. For breakfast the next morning, I ate a quesadilla loaded with black beans, cheese, salsa, lettuce, and guacamole. I’ve had no recurrence of C. diff. since.”

Four pharmaceutical companies in the U.S. reportedly provide stool donors to doctors – mostly for C. difficile infections.  In 2016 the FDA’s decision to require stool banks to provide an expensive investigational new drug application (IND) in order to provide stool resulted in the agency being accused of erecting barriers to treatment which would result, among other things, in more unregulated, home use. Other less restrictive measures were proposed.

Although it’s believed that tens of thousands of fecal transplants have been done safely, the FDA recently reported for the first time that multi-drug resistant infections were transferred via fecal transplants to two people one of whom had died. The death occurred in a man with a compromised immune system who had been given a transplant which had not been screened for a type of resistant E. coli,. As a result, as of July 15th of this year, the FDA is requiring stool transplant companies to screen their poop for a variety of multi-drug resistant organisms.

Conclusion

The first stab at a fecal transplant study in ME/CFS was weak in statistics and strong in vivid detail. Dr. Kenyon’s fecal transplants – used mostly in ME/CFS plus IBS patients –  used only bacterial matter and were done in bulk – ten transplants over ten days – from different donors to ensure that a wide variety of flora was transmitted.

With seven of the 21 treatment resistant patients reportedly returning to full or near normal health, and six receiving significant improvements in energy, the results were surprisingly good.

While the results were promisingly we need more rigorous studies and one, funded by Invest In ME and lead by Peter Johnsen, a Norwegian researcher is underway. Data collection from the 80 person, randomized, placebo-controlled study at the University Hospital of North Norway started in February of this year and is slated to wind up in February of next year. I couldn’t tell how many fecal transplants would be given but changes in gut microbiome, metagenome, metabolome, gut barrier integrity and immune functioning will be assessed at three time points during the year long study.

Johnsen’s 2018 (n=86) study found that fecal transplants “provided significant symptom relief for people with IBS.  (In a nice bit of collaboration Maureen Hanson will be testing some of Johnsen’s samples for gut dysbiosis.)

The Epstein-Barr Virus – Could it be Causing Neuroinflammation in ME/CFS?

EBV has been a virus of interest since almost day one in chronic fatigue syndrome (ME/CFS). In fact, at one point, EBV was such a hot topic that ME/CFS was called for a time “chronic Epstein-Barr virus” disease.

Virion EBV

Epstein-Barr virus virions (circular centers). Virions are the form of the virus which infects other cells. EBV dUTPase is released when the process of creating virions is aborted…

While studies have generally failed to find evidence of EBV reactivation, EBV has never fallen out of the picture with ME/CFS and for good reason. For one, it’s entirely possible that researchers were looking in the wrong place to determine if EBV is an issue in this disease.  For another, EBV infection in adolescence or later and the infectious mononucleosis (glandular fever) it produces, is a common trigger in ME/CFS, and is a proven risk factor for multiple sclerosis.

Besides ME/CFS, researchers are continuing to assess the role EBV may play in many serious illnesses including multiple sclerosis (MS), systemic lupus erythematosus (SLE), Guillain-Barre Syndrome, several cancers,  rheumatoid arthritis (RA), juvenile idiopathic arthritis (JIA), inflammatory bowel disease (IBD), celiac disease, schizophrenia, and others.

Neuroinflammation, of course, is a hot, hot (pun intended) topic in both ME/CFS and fibromyalgia. Recent studies suggest neuroinflammation is present in both diseases and major studies are underway to validate that finding.

Nobody until now, though has attempted to complete the circle, and bring that “original gangster” in ME/CFS – Epstein Barr Virus – and the new guy in town – neuroinflammation – together.  Could EBV be causing or contributing to the neuroinflammation present in the disease?

Some History

Over 10 years of work by an Ohio State University team lead by Maria Ariza and Marshall Williams has been turning the EBV question in ME/CFS on its head. High levels of EBV, they believe, are not the problem in ME/CFS at all. In fact, their studies suggest that EBV may be at its most dangerous in ME/CFS not when it reactivates – but when it fails to reactivate properly.

dTUPase model

The Ohio State University dUTPase continuing NIH grant is in its 9th year.

By the time the impaired immune systems of people with ME/CFS have started knocking down EBV’s attempt at reactivation, the bug has already produced a potentially pathogenic protein called dUTPase. The Ohio State University researchers believe this protein may be wreaking havoc in a large subset of people with ME/CFS.

With the NIH supporting them every step of the way – their continuing grant on dUTPase is now in its 9th year – the evidence that this protein is contributing to ME/CFS (and other diseases) has continued to build.

In 2012, the group found evidence that the immune systems of people in a large subset of ME/CFS patients were indeed battling this protein. Just a year later they showed that even when viral loads of EBV were low, dUTPase could still be triggering a significant pro-inflammatory response. That finding suggested that failed prior attempts to link EBV reactivation to ME/CFS were barking up the wrong tree.

Two years later, they demonstrated that dUTPase was able to make its way into exosomes (now a major topic of interest in ME/CFS), cross the blood-brain barrier, produce major immune effects, and perhaps even promote further EBV infections.

Then a 2017 study added another herpesvirus long suspected in ME/CFS – HHV-6 – to the mix. That study found antibodies to dUTPases produced by both EBV and HHV-6 in almost fifty percent of the ME/CFS patients.  That suggested that the two herpesviruses might even be reactivating each other – a feature found in some very immune suppressed states including organ transplant patients and drug induced hypersensitivity syndrome.

Then again, really significant immune suppression in ME/CFS may not be a surprise. Up to 75% of ME/CFS patients were found to have low numbers of the B-cells designed to keep EBV in check in a recent study.

If the immune system wasn’t having enough trouble, in 2017 the first evidence of an autoimmune process involving EBV dUTPase was found in ME/CFS. Autoantibodies to the human dUTPases (humans produce a dUTPase as well) were found in ME/CFS – at much higher levels than in healthy controls (39% vs. 5%). That suggested that the immune response to EBV and HHV-6 dUTPase may have gone awry in some people with ME/CFS. Their bodies were now attacking their own human dUTPase.

The 2019 Study

In the present study we provide further evidence…. (that) dUTPase protein…could contribute to the development of a neuroinflammatory microenvironment in the brain(s) (of a subset of ME/CFS patients.)  The authors

Epstein-Barr Virus dUTPase Induces Neuroinflammatory Mediators: Implications for Myalgic Encephalomyelitis/Chronic Fatigue Syndrome. Marshall V. Williams PhD; Brandon Cox ; William P. Lafuse PhD; and Maria Eugenia Ariza, PhD. Clinical Therapeutics March 2019

In 2019, the team took another step. In an earlier study they’d demonstrated that the EBV dUTPase protein could be causing or contributing to the symptoms present in ME/CFS. Since many of these symptoms can be produced by the brain, they next asked if the enzyme could be affecting the integrity of the blood-brain barrier (BBB) and other aspects of neuroinflammation.

There’s a pretty good reason to believe this might be the case. EBV, after all, has been associated with some pretty nasty neurological diseases. The virus loves to hang out in nerve cells and astrocytes, is a risk factor for M.S. and has, in fact, been found scattered throughout the astrocytes and microglial cells in MS patients’ brains.

The Ohio State University researchers plopped the dUTPase protein into a variety of cells and then determined how it affected the expression of genes that play an important role in maintaining the blood brain barrier (BBB) and the functioning of various brain cells (cerebral microvascular endothelial cells, astrocytes, microglia cells).

The big bug’s dUTPase protein turned out to be quite adept at tweaking genes and proteins associated with the BBB and neuroinflammation. It turned on 12 of 15 genes and 32 of the 100 proteins examined in vitro (in the lab) and 34 of the 84 genes examined in mice.

The fact that these genes play a role in BBB integrity/function, fatigue, pain synapses and their functioning as well as tryptophan, dopamine, and serotonin metabolism suggested that this enzyme, in or out of the brain, could conceivably cause widespread problems.

How the Blood-Brain Barrier Works

 

 

All in all, the protein appeared to be doing its best to find a way to get EBV into the brain. That’s perhaps not a surprise given how much EBV loves to hang out in neurons. As EBV dUTPase was down regulating the expression of genes dedicated to producing a tight BBB it was “strongly” inducing the expression of two cytokines (IL-6 and IL-1β) known to disrupt The BBB.

If EBV dUTPase gets inside the brain, it seems almost guaranteed to cause neuroinflammation.  Studies indicate it can trigger microglial cells and astrocytes (star-shaped immune cells in the brain) to produce potent pro-inflammatory cytokines (IL-6, IL-1β and TNF-α). It also prompts astrocytes to produce a substance (PTGS2/COX-2) associated with neuroninflammatory toxicity. Plus it’s able to alter the expression of genes associated with pain (GPR8451 and GCH152) and fatigue (TBC1D153) to boot.

In mice, it altered the expression of genes associated with cognition (synaptic plasticity, learning and memory).  One of the more intriguing findings, given the possible disruption of the kynurenine pathway in ME/CFS, was the protein’s potential to increase synthesis of a potent neurotoxin called quinolinic acid. Genes associated with the metabolism of two of the major neurotransmitters in the brain, dopamine, and serotonin, were also affected.

EBV dUTPase neuroinflammation

If EBV dUTPase has indeed been able to get into ME/CFS patient’s brains it seems almost guaranteed to cause neuroinflammation

All in all, EBV dUTPase is not a protein anyone wants hanging out in their head. It is, however, a protein that could potentially produce a lot of the problems found in ME/CFS.  This study demonstrated that the protein appears to have the capability to make its way to ME/CFS patient’s brains. Determining if it has will take further investigations, however.

It should be noted that the protein and its antibodies (or the autoantibodies to the human dUTPase) are not found in everyone with ME/CFS but the potential subset – ranging from 30% to 60% of those tested so far, is pretty darn large.

Plus, the virus is heavily implicated in the stress response. If you feel like your nervous system is over-reacting to, well, anything (or everything), EBV and this protein could be a factor. Of all the viruses, EBV and the herpesviruses love most to come out and play when one’s system is stressed.

In fact, Ron Glaser, one of the initiators of the EBV dUTPase research effort, demonstrated back in 1991 that EBV thrives in situations of psychological stress. Given the enormous stress people with ME/CFS are under, and the affects the illness has on both axes of the stress response, it makes sense that the virus might be continually trying to reactivate – and spilling it’s toxic protein into the bloodstreams of some people with this disease.

A Good-bye to a Pioneer

Ron Glaser

Glaser was shocked he couldn’t get his ME/CFS grant applications funded at the NIH

Ron Glaser was something of a legend in his own time. With his doctorate in pathology, his EBV citations alone total over 100. All told he published over 300 papers. Glaser co-founded Institute for Behavioral Medicine Research, which under his leadership brought in over 140 million in grant money over 20 years. At one point he was one of the world’s most cited authors.

His memorials mention his impact on the psychoneuroimmunological (PNI) field, his enthusiasm, (and the red and white Corvette he loved). What they don’t mention is that this leader also devoted time to a much neglected field called chronic fatigue syndrome. Glaser, in fact, took the time out of his busy schedule to sit on the now disbanded federal advisory committee for ME/CFS (CFSAC).

I vividly remember talking to him. He was not a man to mince words. An accomplished researcher with a long history of grant success, Glaser was first shocked, and then very angry at the rejections piling up for his ME/CFS grant applications. He just couldn’t understand it. Never in his decades of work had he experienced such a thing.

Stating, ironically, he couldn’t stand the stress (he did look like he was about to burst a blood vessel), he eventually moved on, but not before making his experiences perfectly clear to the federal advisory committee and everyone around him.

Glaser was not happy at not being able to work more in ME/CFS, but the work he did did not go for naught. Glaser first published on EBV dUTPase in 1985 and on EBV and ME/CFS in 1988 and his work lives on in Ariza and William’s studies on ME/CFS today. Check out a memorium to Ron here. 

Marshall Williams – On the Continuing Hunt for EBV dUTPase in ME/CFS

What about the connection between this protein and the presence of infectious mononucleosis/glandular fever in ME/CFS? Do we have any idea if the enzyme is more likely to be found in people who’s disease was triggered by IM or who had an acute, flu-like onset?

That is an excellent question. We are in the process of trying to obtain longitudinal serum samples from an IM cohort who developed CFS as well as age matched patients who had IM but never developed CFS. Hopefully, that may address this question.

EBV dUTPase exosomes

When EBV (lytic) replication is aborted it tosses EBV dUTPase into exosomes (circles with red marks) which, after binding to TLR receptors on immune cells, tells those cells to turn on proinflammatory and other genes (from Ariza, Williams and Glazer -https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0069827)

This study demonstrated that this enzyme has the potential to disrupt the BBB and enter the brain – and as added bonus – perhaps helps get EBV into the brain. Is there any way to tell if this has actually happened in ME/CFS?

Not really at this point but maybe in the future. Screening CSF from ME/CFS patients for antibodies to the EBV-dUTPase or HHV-6 dUTPase might suggest potentially the presence of these viruses in the brain.

Exosome research is heating up in ME/CFS. Some anecdotal reports show that exosomes in the blood may be affecting energy metabolism and other functions. Could herpesvirus dUTPases be involved? Is there any more information on exosomes and EBV dUTPases?

We have not looked at energy metabolism but there are some reports in the literature that some herpesviruses including EBV and HHV-6 alter mitochondrial function. There is information concerning EBV products in exosomes but most of these have focused on proteins/microRNAs involved with latency.

What is next for your team? 

We are in the process of submitting a manuscript detailing a mechanism(s) by which the EBV-dUTPase and to a lesser extent the HHV-6 dUTPase alter germinal center function, which could contribute to autoimmunity in CFS patients. We will be continuing these studies as well as those regarding neuroinflammation. (B-cells manufacture autoantibodies in the germinal centers found in the lymph nodes and spleen)

Epstein-Barr Virus May Be Turning On Pathogenic Genes in ME/CFS

If there was ever a “prodigal virus” in ME/CFS it would surely be the Epstein-barr virus (EBV). Since the first EBV ME/CFS study 1984 no less than 51 ME/CFS or post-infectious viral studies have featured either Epstein-Barr virus or infectious mononucleosis in their titles. (That leaves out a considerable number of viral and immunological studies which didn’t put EBV in their titles.) While hypotheses of chronic viral reactivation in ME/CFS have lost favor the virus is too complex, too fascinating, and simply too problematic for it not to continue to be studied.

EBV budding out of B-cell

A B-cell with EBV budding out of it

A PubMed search brings up over 500 EBV citations associated with multiple sclerosis and over 30,000 citations associated with the virus.  To get an indication of how broad EBV research continues to be – one of the latest  EBV studies determined if the stress of space flights results in increased levels of EBV reactivation in astronauts. (It did and they advised astronauts to stay away from immunocompromised individuals upon return home…)

The research community clearly continues to find EBV – one of the few viruses our bodies are unable to kick out – a fascinating and important topic. Check out the first in  a series of two blogs on EBV’s possible contributions to ME/CFS.

The Review

In his EBV and ME/CFS review longtime ME/CFS researcher Jonathan Kerr digs down into some past ME/CFS EBV findings which recent understanding of EBV is shedding some new light.

Kerr notes that psychological stress is associated with EBV reactivation and maintaining that state of psychological stress can result in prolonged states of EBV reactivation and diseases such as ME/CFS, nasopharyngeal cancer and post-transplant lymphoproliferative disorder (PTLD).

Many studies have found that stress triggers the release of glucocorticoids which tell the pathogen that the coast is clear and it’s time to start growing the family and producing more virions.

Whether or not the original ME/CFS trigger is associated with increased levels of  psychological stress, the dysfunctions found in both stress response axes (HPA axis, autonomic nervous system) post-ME/CFS suggests that psychological stress could  possibly give a bug like EBV a leg up in diseases like ME/CFS. Plus, other studies have found evidence of an immune hole which could give EBV an extra foothold in ME/CFS.

In the U.S., Ariza and Williams have shown that attempts at EBV replication in ME/CFS can trigger the production of an enzyme called EBV dUTPase which, among other things, results in the production of pro-inflammatory cytokines which may produce fatigue, pain, flu-like symptoms, etc.

Kerr’s group in the U.K., though, has taken a different tack.

The 2008 Study

Assessing the expression of 88 genes Kerr suspected were playing a role in ME/CFS, his group was able to separate healthy controls from ME/CFS patients, and then break those ME/CFS patients into 7 subsets in 2008. No less than 12 of the genes his group assessed were known to be associated with EBV.

Finding such a huge split in gene expression between ME/CFS patients and healthy controls, and then being able to split up the ME/CFS group into gene expression subsets with unique symptom profiles, was striking.

One of the genes which stuck out back then is called Epstein-Barr Virus (EBV) induced gene 2 (EBI2). While EBI2 sounds like it comes from EBV, it’s a human gene. As EBV begins to reactivate it induces the expression of this gene, which regulates B-cell functioning, T-cell mediated antibody responses, and inflammation.

Kerr’s 2008 study suggested the gene was working overtime in 55% of ME/CFS patients. In another analysis, EBI2 was upregulated in 38% of 31 patients vs zero of 40 healthy controls.

The 2010 Study

A larger (n=117 ME/CFS patients) 2010 study analyzed antibodies associated with EBV in eight gene expression subsets. As before, twelve of these genes were known to be associated with Epstein-barr virus (EBV)

EBV Gene 2 expression

Greatly increased expression of the EBV Induced Gene 2 was found in the ME/CFS group

One subset – subset D – stood out in its severity. This group of patients, all females, demonstrated a consistency of the worst kind, posting the lowest functional scores  in no less than five of SF-36 functional domains (physical role, vitality, general health, bodily pain, and total score) and experiencing high rates of muscle pain and sleep issues.

They also led the pack in the expression of  EBV associated genes. Their EB12 genes were turned on and pumping away at higher levels of activity than in any of the other groups. So were all the other 11 associated EBV genes.

In other words, this appeared to be a highly afflicted EBV ME/CFS subset.  EBV may be involved in other subsets, but it appeared to be wreaking special havoc in this one.

Interestingly, the abnormal antibody (EBNA IgG) result found indicated the antibody was not elevated but was reduced. Since antibodies play a key role in immune clearance, the low levels suggested an immune deficit could be present.  For one, they suggested EBV was probably more often found in its latent state in this group.

EBV is found in two forms: its lytic form occurs mostly in epithelial cells, and its latent form in B-cells.  The low levels of EBNA IgG appear to suggest, if I have it right, that EBV is able to survive in B-cells longer, giving it more time, one would think, to possibly tweak those B-cells more. That’s an interesting finding given the role B-cells play in autoimmunity.

Nine Years Later – Science Marches On

Nine years ago, not much was known about EB12 but science has been moving on. EB12 is now recognized as a “critical regulator of the immune response”. It ordinarily plays a valuable role in the interaction between B and T-cell and the antibody response.

Gene expression

Jonathan Kerr believes EBV may be causing a gene to over express itself in ME/CFS

As one might suspect, though, EBV activation of this gene is not associated with good outcomes.  Increased EBI2 expression appears to dysregulate the delicate immune response – increasing B-cell activity (and therefore the risk of autoimmunity)  – while inhibiting T-cell activity – and potentially suppressing the immune system’s ability to deter pathogens and knock out cancerous cells. Kerr pointed out that EBI2 could also be contributing to the reduced cerebral perfusion, gray matter reduction and white matter hyper intensities found in both multiple sclerosis and ME/CFS.

Given the findings of the past 11 years, Kerr suggested that the EB12 gene deserves a deeper look in this disease.  The possibility that a severely ill EBV subset – characterized by a hyperactivation of the EBI2 gene – is present, is, of course enticing. Given that ME/CFS often has an infectious trigger, a special EBV subset makes perfect sense, and if it is present, it may offer some unforseen opportunities.

One of the advantages of having an upregulated gene that’s been implicated in a bunch of nasty diseases is possible increased interest from big pharma. If the EBI2 gene is wreaking havoc in some of the more severely ill ME/CFS patients, help may be at hand in the future.  Kerr pointed to two EBI2 modulators  (GSK682753A, NIBR189) currently under development.

Kerr acknowledged several caveats to his hypothesis. His findings need to be validated by other laboratories using other sets of ME/CFS patients. He noted that finding EBV antibodies in ME/CFS does not in any way indicate that the bug is causing ME/CFS – that is still in doubt. His hypothesis – that EBI2 upregulation is playing an important role in a subset of ME/CFS patients –  is unproven at this point.

It’s a hypothesis though, which is consistent with the data presented thus far and could account for “many of the immune and neurological abnormalities” found in a group of patients.

MAIT Immune Cell Findings Unite U.S. and U.K. ME/CFS Researchers

The US and the UK are said to have a “special relationship”. That special relationship hasn’t generally extended to ME/CFS research, given a decidedly different focus on ME/CFS in the two countries – a strong focus on biological research in the US and more of a focus on CBT/GET in the UK.  That might be changing, though.

Derya Unutmaz at Jackson Labs and Jacqueline Cliff of the London School of Hygiene and Tropical Medicine | LSHTM appear to have both independently landed on the same immune cell in chronic fatigue syndrome (ME/CFS). Given the multitude of immune cells found in the body, that has the potential to be rather special.

UK ME/CFS Biobank

A large NIH funded UK Biobank enabled these researchers to produce one of the largest ME/CFS immune studies done.

The specialness doesn’t stop there. The samples tested by these two teams – all 300 of them – come from the UK ME/CFS Biobank – which since 2014 has received major funding from the National Institutes of Health (NIH) in the US. (The Biobank has also received funding from The ME Association, Action for ME, and ME Research UK.) Plus, the NIH provided most of the funding for the Cliff project.

The UK ME/CFS Biobank is big. It contains serum, plasma, peripheral blood mononuclear cells (PBMC), red blood cells/granulocyte pellet, whole blood, and RNA samples from over 500 ME/CFS and multiple sclerosis patients and healthy controls. Plus, it includes an extensive dataset of 700 clinical and socio-demographic variables.

The Cliff study focused on the immune system – a natural system to target given the infectious onset many experience and the symptoms common to all patients. An immune “hole” could give a pathogen time to do more damage, set off an autoimmune response, or alter immune functioning in some other way.

Immune studies in ME/CFS are not uncommon, but the Cliff team researchers (sounding very English at least to my ears) described their results as “discrepant” and inconclusive. Interesting research findings have not been reproduced in ME in part, they asserted, because of small study sizes, varied research methods, and sometimes a less than stellar quality of the studies.

This Biobank study is different, they believe. A large study with a well characterized patient group, they clearly believe its results will stand the test of time.

The Study

Front Immunol. 2019 Apr 16;10:796. doi: 10.3389/fimmu.2019.00796. eCollection 2019. Cellular Immune Function in Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS). Cliff JM1, King EC1, Lee JS1, Sepúlveda N1,2, Wolf AS1, Kingdon C3, Bowman E3, Dockrell HM1, Nacul L3, Lacerda E3, Riley EM1.

The Patients

The Cliff study examined the samples from over 400 patients and controls (251 ME/CFS (54 severely affected and 197 mild/moderate), 46 multiple sclerosis, 107 healthy controls.)

The patients met either the Canadian Consensus Criteria or the 1992 Fukuda Criteria (or both) and were mostly recruited via the UK National Health Service. The patients were determined to meet either criteria after their responses to a Symptoms Assessment form were fed into a computerized algorithm that maps their symptoms onto the different ME/CFS study case definitions.

Since the Fukuda definition does not require post-exertional malaise – the core symptom of ME/CFS –  it was surprising to see the group potentially accept patients who only met that definition. It wasn’t clear from the study what proportion of patients, if any, met only the Fukuda criteria, though. Severely ill patients were mostly home or bed bound. Their blood samples were taken during home visits.

People who had taken antiviral medications or drugs known to alter immune functioning, had a recent history of vaccination, had a history of other chronic diseases such as tuberculosis, cancer, uncontrolled diabetes, etc., had a severe mood disorder, or who had been pregnant or breastfeeding in the past 12 months were excluded.

One part of the study focused on natural killer (NK) cells – key players in the early, innate immune response. Given the NK findings in ME/CFS, the group’s decision to analyze NK cells was not a surprise, but they gave their analysis a twist. Because cytomegalovirus (CMV) infections have such profound effects on our NK cells (and the rest of our immune system), the relationship between CMV infections and NK cells was assessed to determine whether a past CMV infection could be responsible for the NK cell abnormalities seen in ME/CFS.

Results

The Next Big Thing in Immune Research? MAIT cells Pop Out Again

The big news from the Cliff study is the increased frequency of the CD8+ mucosal associated invariant T cells or MAIT cells.  The UK authors noted that an increased frequency of MAIT T-cells has not been published before, which is true, but Derya Unutmaz, leader of the NIH ME/CFS Research Center at the Jackson Labs, has been talking about them in ME/CFS for several years.

MAIT cells

MAIT cells form a bridge between the gut and the immune system. (From Dr. Oh’s NIH Conference presentation)

Unutmaz reported finding high levels of MAIT cells in ME/CFS patients.  Unutmaz’s findings suggest that the MAIT T-cells have been repeatedly activated in ME/CFS and that they evidence the same activated/burned out pattern he’s found in other T-cells.  He and Dr. Oh at Jackson Labs are trying to determine which stomach bacteria has turned them on and then find a way to eliminate or reduce it.

MAIT cells are known for the role they play protecting the lining of the gut against toxic bacteria. Their name – mucosal invariant T-cells – derives from the high levels of these cells gathered around the mucosal surfaces of the gut (e.g. the lining). In effect they are the gut’s innate immune cells – sentinels guarding the gut wall which can, in contrast to other T-cells, react immediately to invaders.

They’re different from other T-cells which get activated after being triggered by an antigen from a pathogen. Instead, they’re activated by fats and vitamin B2 metabolites produced by plants, bacteria (E. coliPseudomonas aeruginosaKlebsiella pneumoniaL. acidophilusS. aureus, and S. epidermidisC. albicansC. glabrata, and S. cerevisiae ) and fungi. Because cytokines produced by viral infections can activate them as well, the high degree of MAIT cell activation is not necessarily due to bacteria in the gut – but it’s the most likely scenario.

MAIT research only started popping up after 2010, when studies revealed these unusual cells were able to detect bacteria and fungi and respond with pro-inflammatory cytokines. Since then many studies have suggested that MAIT cells play an important role in infectious diseases, autoimmune diseases and cancer. MAIT cells are not always pro-inflammatory, but increased levels, particularly of cytotoxic MAIT cells, are believed to be associated with pathogenic states.

In contrast to Unutmaz’s apparent (but unpublished) findings of high levels of MAIT cells in ME/CFS overall, this study found a high proportion of MAIT cells only in the severely ill ME/CFS patients. They noted that a small number of the severely ill patients were reported to have “exceedingly high” frequencies of these cells.

Most of the MAIT cells in the severely affected ME/CFS patients (as well as in the MS patients) were in their cytotoxic (killing) form.  They’d probably been activated by a bacterium in the gut and were apparently on the prowl, ready to pounce. While the increased proportion of MAIT cells only weakly discriminated the severe ME/CFS patients from the healthy controls, the high percentage of killer T-cells (cytotoxic T-cells) found was moderately discriminative.

Interestingly, the Cliff study authors pointed out that peripheral MAIT cell levels in healthy volunteers can increase 2-fold following exercise. Finding similarly high levels of MAIT cells in the severely ill patients suggested they were in a similar post-exercise state without having engaged in any exercise.

Slight Increase in ESR Surprises

Interestingly, symptoms associated with inflammation/infection were more common and more severe in the ME/CFS cohort than in the MS cohort (go figure!). Perhaps that’s not a surprise, since ME/CFS has been shown to impact functioning to a greater degree than MS.

The slight raise in erythrocyte sedimentation rate (ESR) – an inflammatory marker – in mild/moderate cases of ME/CFS compared to the other groups (Including the severe ME/CFS group) was surprising, though, given that very low ESR’s are thought to be typical in this disease.

Laboratory studies. These tests can be used to exclude other diseases associated with fatigue. The most consistent laboratory abnormality in patients with CFS is an extremely low erythrocyte sedimentation rate (ESR), which approaches zero. Typically, patients with CFS have an ESR of 0 to 3 mm/h. A normal ESR or one that is in the upper reference range suggests another diagnosis. https://www.consultant360.com/content/chronic-fatigue-syndrome-update-diagnosis-primary-care

Natural Killer Cells

As the Cliff study introduced a new factor into ME/CFS research (MAIT cells), it took a hatchet to the last big immune finding in ME/CFS – natural killer cells. The study found no significant differences in NK cell proportions, types, KIR receptors or activation markers before or after they stimulated them.

Some NK markers did stand out, but only in patients who had been exposed to CMV. The authors suggested a past CMV infection in some of the ME/CFS patients had likely caused the NK cell abnormalities in ME/CFS – not ME/CFS.

The Cliff study, however, used a different test of NK cell functioning than some groups have used in the past. The British group assessed both T and NK cell functioning by determining how the cells responded to stimulation; i.e., did they produce distinctive markers and/or start producing cytokines. The ME/CFS patients’ cells apparently whizzed through that test – they perked up and started producing cytokines, leaving the authors to report that no functional issues with these cells are present.

NK cell functioning

The Cliff study suggested that the NK cell findings in ME/CFS may be due to patients with past CMV infections. They did, not, however, use a NK cell functional test used by others in the past.

Dr. Klimas, however, uses a more direct functional NK cell assay which measures the number of target cells killed. Plus, instead of the PBMC’s used in the Cliff study, she uses whole blood – possibly a critical factor, given Ron Davis’ and Fluge’s findings that something in the plasma is affecting the cells. In fact the first hint of a blood-borne factor in ME/CFS showed up in NK cell studies.  That idea that something in the blood was impacting functioning first showed up when Dr. Klimas realized that a study which found no evidence of problems with NK cell functioning had not used whole blood in its tests.

The UK study authors noted that small study sizes have hampered immune results in this disease, but size was not an issue for the 2011 Klimas/Fletcher study (176 ME/CFS patients, 230 healthy controls) which found significant declines in NK cell functioning, and those declines were associated with increased fatigue levels. In an Australian study, Brenu also used a target cell killing test to show reductions in T-cell functioning. The UK study authors did not allude to other possible functional tests or the whole blood issue in their manuscript.

Exhausted T-cells?

The UK study authors did find a number of T-cell abnormalities: increased proportions of effector memory CD8+ T cells, decreased proportions of terminally differentiated effector TEMRA cells, and some minor changes elsewhere – whose effects are unclear. The UK authors suggested, though, they could be due to “ongoing antigenic stimulation” due to an unresolved infection or autoimmunity.

Either could presumably produce a state of “immune exhaustion” which some have hypothesized is present in ME/CFS.

Derya Unutmaz focused on key players in autoimmunity and inflammation called TH17 cells in his U.S. study. He wasn’t surprised to find high levels of TH17 cells – which are regulated by the gut –  but he was shocked to find low levels of the IL-17 cytokine they produce. That finding also suggested that the immune cells in ME/CFS might be in a state of exhaustion.

The Cliff study’s IgG antibody tests found no evidence of increased herpes virus reactivation in ME/CFS, and some evidence of it in MS. The group didn’t close the book on the possibility of herpesvirus reactivation in ME/CFS, though, stating that other antibody tests for EBV might produce different results.

Conclusion

The Cliff study was a large UK Biobank study using both Fukuda and/or Canadian Consensus Criteria to identify its patients. The study’s finding of moderately increased ESR levels in the mild/moderate patients was surprising, given past reports of low ESR levels in ME/CFS.

Except in patients who have been exposed to cytomegalovirus (CMV) in the past, the study found no evidence of natural killer cell issues in ME/CFS. The researchers did not, however, use a functional assay used successfully in the past which more directly measures NK or T-cell killing capacity.

The study’s major finding was a significant increase of specialized T-cells called MAIT cells in the severely ill patients. MAIT cells are found across the body but are most known for the role they play protecting the gut lining from toxic bacteria. High levels of MAIT cells have been associated with infectious diseases, autoimmunity and cancer.

This is the second recent and, it should be noted, independent report of high levels of MAIT cells in ME/CFS. In fact, these two reports are the first time MAIT cells have been implicated in this disease.

Dervy Unutmaz and Dr. Oh of the Jackson Labs are currently trying to isolate the bacteria triggering the high levels of MAIT cells they’ve found in ME/CFS.

The Cliff study did find moderate T-cell anomalies which could possibly reflect a state of chronic T-cell activation caused by an infection or autoimmune response. Derya Unutmaz also recently reported he’d found evidence of immune cell exhaustion in his T-cell studies.

East African Disease Informs Nath’s Search for the Cause of ME/CFS

Could a disease found in the remote villages of East Africa end up being a model for chronic fatigue syndrome (ME/CFS)?

Ugandan Village

Ugandan Village (from the NIH)

Dr. Avindra Nath – the leader of the NIH Intramural study on ME/CFS –  thinks perhaps so. He’s not daunted by mysterious diseases and nor should he be. Just a couple of years ago his NIH team was able – by bringing new technology to bear – to unravel a mysterious disease plaguing children in Africa. Using a much larger array of tests he’s hoping to do the same in ME/CFS.

Nath became acquainted with “nodding syndrome” at a meeting in Uganda in 2012. This strange and often devastating disease, found in the remote regions of Uganda, Tanzania and South Sudan, causes children’s heads to periodically nod  and can produce seizures, mild to severe cognitive impairment, muteness, gait problems, paralysis and often death. Brain scans have shown significant brain atrophy.

Studies suggested that the disease was linked to a parasite, Onchocerca volvulus, carried by the black fly, but numerous efforts to find the parasite in the brain or cerebral spinal fluid failed.  Attempts to tie it to immune factors including autoantibodies, as well as genetics, toxins, nutritional factors, and others came to naught as well.

Like ME/CFS the speculation regarding the cause of nodding syndrome has been rife with possible connections to autism spectrum disorder, Alzheimer’s, poor nutrition, PTSD and others being put forth. Ugandan psychiatrists have even proposed that the disease is a form of “Developmental Trauma Disorder” brought on by the war.

Enter Nath, Tory Johnson, a former postdoc fellow of his, and Thomas Nutman, a National Institute of Allergy and Infectious Disease (NIAID) researcher.  Suspecting the problem was autoimmunity, they brought out one of their big guns – a kind of protein chip technology that allowed them to screen for thousands of antibodies at once.

The results were tantalizing. The levels of four antibodies were 100 fold higher in the sick children compared to the healthy children.  Further testing revealed that two of these antibodies were more reactive or active in the sick children. They ended up focusing on one antibody found in both the blood and cerebral spinal fluid.

This antibody – which was linked to the leiomodin-1 protein  – reacted 33,000 times more strongly in the children with nodding syndrome.  Interestingly, both groups – the sick and the healthy children – carried the antibodies, but they were elevated in the sick children.

Leiomodin-1 staining neurons

Staining reveals Leiomodin-1 antibody (green) interacts with human neurons

After finding this link, they deepened their search. The leiomodin-1 protein had been found primarily in smooth muscle tissue and the thyroid, but if it was causing the neurodegenerative symptoms it had to be in the brain as well. Further testing, including immunostaining human neurons, indicated that protein was indeed found in parts of the brain imaging studies had indicated were associated with nodding syndrome.

Having established a putative link between the antibody and the disease (that it was found in and could potentially affect the brain) the next step was to demonstrate that the antibody could indeed be causing the disease. Subjecting cultured human neurons to the antibody showed that the antibodies could indeed be damaging the childrens’ neurons.

Getting at the source of the antibody was next. The authors hypothesized that an immune attack against the parasitic worm had gone awry and was attacking the ill childrens’ neurons. This could only happen, though, if the parasitic worm and human neurons shared genetic sequences that could cause the immune system to mistakenly attack human neurons. Studies confirmed that a very short sequence of the parasite’s tropomyosin gene was quite similar to a sequence expressed in human neurons.

autoimmune responses ME/CFS

Nath believes the infections may have triggered a variety of autoimmune responses targeting the brain in ME/CFS

With that, the circle was closed. They had identified an antibody, shown it was in the brains of the sick children, showed that it could do damage to the neurons that were damaged in the children, and demonstrated similar genetic sequences were present in the parasite and humans.

There was still the nagging issue of antibody prevalence, though.  Only slightly over 50% of the sick children had antibodies to leiomodin-1. If the antibody to leiomodin-1 was causing the disease in these children, what was causing the disease in the others?

Nath et al proposed that the parasite triggers a different immune response in different children.  Some of the children developed autoantibodies that damaged neurons in their CNS  – and produced nodding syndrome (which is now understood to be a form of autoimmune epilepsy).

This syndrome is likely not a disease mediated by a single immune specificity. We speculate that nodding syndrome may not be a single antibody syndrome.  Nath et al.

Citing test results which showed a range of elevated autoantibodies in the sick children, they suggested that some children with nodding syndrome have developed antibodies to  neuronal proteins other than leiomodin-1.

A Model for Chronic Fatigue Syndrome (ME/CFS)?

Nath reported that his approach to ME/CFS has been shaped by his experiences with nodding syndrome. He suspects the infectious onset that so many people with this disease experienced triggered their immune system to accidentally produce autoantibodies that are attacking their central nervous system or other parts of the body.

If suspect antibodies show up, future research efforts will presumably proceed down the same pathway as they did in Nodding Disease: first they will identify the proteins the antibodies are attacking, and then they will determine where those proteins are found, and demonstrate experimentally that the antibodies are likely doing damage.

Nath and his compatriots uncovered the antibody connection to nodding disease seven years ago – a long time in this age of fast moving medical technology. Nath reported he’ll be using a newer approach involving mass spectrometry, or phage display, in ME/CFS which will allow him to “probe almost infinite numbers of proteins/peptides”.

Seven years ago, extensive testing had failed to find a culprit leaving the cause of nodding syndrome a complete mystery. In 2017 Nath et. al. produced a clear pathway that explains about 50% of nodding syndrome victims.

Technology Paves the Way

Note that the breakthrough didn’t come from the slow accumulation of results over decades; –  it occurred very quickly and simply required the right technology being applied to the disease. When that happened, a cause of the disease became clear, and researchers simply proceeded down established pathways to prove  it.

Nath and the NIH are looking at much more than antibodies in their intramural study, and ME/CFS, with its multiplicity of triggers, is likely to be more complex than nodding syndrome. The same principle, though, – a variety of autoimmune processes produced by an infectious trigger – may apply.

Dr. Nath appears to have gotten at a cause of one mysterious disease. May he be as successful with this one.

Check out an interview with Dr. Nath

Dr Nath Talks on the ME/CFS NIH Intramural Study

The NIH’s Accelerating Research on ME/CFS Conference

Because of a death in the family, Brian Wallitt will be presenting in Dr. Nath’s place at the NIH conference. Dr. Nath reported that Wallit will present on the high rate of rare diseases found during the first half of the study and some other data but will not present statistical analyses. With just half of the projected participants having finished the first part of a two-part study, the lack of statistical analyses is not really a surprise.

Brian Wallitt will be presenting at 10:00 AM EST on April 5th (day two) of the Accelerating Research on ME/CFS conference – the first NIH sponsored research conference on the disease since 2011. Check out the agenda here.

Learn more about the NIH Conference below.

NIH Brings in New Faces and Looks to the Future in Accelerating ME/CFS Research Conference

A Former Doctor Goes Through the NIH’s ME/CFS Intramural Study

Robert’s Story

Robert, an MD, is board certified in internal medicine. After the worst flu-like illness he ever had, he ended up in the hospital.  A regular exerciser prior to becoming ill, his legs were so weak that he could hardly walk afterwards.

His path to a chronic fatigue syndrome (ME/CFS) diagnosis was rapid. Three months of testing left him no other conclusion – it was clear to him that he had ME/CFS.  He was able to work on and off for a few years, but his health has deteriorated. He’s been unable to work for the last three years.

ME/CFS diagnosis

Robert, a former MD, was able to rapidly diagnose himself but remains severely ill.

Thankfully, he had a wide array of doctor friends who knew him before he became ill and didn’t encounter the skepticism and invalidation so commonly experienced in our community. He noted that our current medical culture doesn’t offer much for the complex patient. Doctors are busy and often time-constrained and if you don’t fit into one of the medical pigeon-holes, they don’t have much to offer.

Rating his level of health on a scale of 1-10 at 2, he’s one of the sickest, if not the sickest, ME/CFS patient to participate in the grueling two-part intramural study at the NIH. He was the first patient to go through the second phase of the Intramural trial which involved, among other things, the exercise study and an extended stay in a metabolic chamber.

One theme – validation – cropped up several times during Robert’s week long stay at the NIH hospital in Maryland. It was clearly apparent from the gestures of sympathy from the occupational therapist during a test to assess functioning.  Given cards which identified an activity, Robert put them into two piles – activities he used to do and activities he still did. The occupational therapist – who has probably given this test hundreds if not thousands of times – registered dismay at the few cards left in his “still do” pile. Those few cards left made the extra level of devastation that ME/CFS is so good at causing clear. It’s rare for people who are not elderly to be so sick.

Given his abysmal level of functioning, Robert’s willingness to participate in a study that Dr. Nath thought few might be willing to undergo was a real testament to the courage and determination that so impressed Dr. Nath. Despite Robert’s low functional level (1-2 on a 10-point scale), he was disappointed that the NIH was not doing a two-day exercise test (!).

The second part of the study is centered around the exercise stressor. Participants do cognitive testing, blood tests, the Seahorse mitochondrial test, a functional MRI and transcranial magnetic stimulation before and after the maximal exercise test.  (The NIH communicated with the Workwell Foundation on doing the exercise test with ME/CFS patients).

Exercise is finally getting its due in ME/CFS, and over the next couple of years several large studies should tell us much. With its extensive blood draws and millions of data points, Dr. Klimas’s exercise studies have informed her models of ME/CFS and laid the foundations for her clinical trial.  With help from the Solve ME/CFS Initiative, David Systrom has added gene expression to his already complex invasive cardiopulmonary exercise testing.  Maureen Hanson has incorporated exercise into her large NIH Research Center studies at Cornell, as well.  None of these studies, though, can match the sheer breadth of this NIH exercise study with its brain scans, lumbar punctures, Seahorse data, blood draws, etc..

Metabolic Chamber

Robert spent about three days in the metabolic chamber – a sparse box containing a bed and a toilet that’s designed to produce precise measures of metabolic activity – before and after the exercise test.  (I will expand on the metabolic chamber).  He wore an EEG, blood pressure and Holter monitor, while in the chamber.

Only thirty metabolic chambers exist in the world, and three of them are at the NIH. With 400 metabolic chamber studies underway every year, they’re pretty much in use all the time. These airtight 11-by-11.5-foot rooms aren’t much to look at or stay in: they come with a bed, an exercise bike, a toilet, and nothing else. Precisely measured meals are delivered through a small, air-locked opening in the wall.

metabolic chamber NIH

An early metabolic chamber at the NIH in 1957

Metal pipes running along the ceiling that measure oxygen consumption and CO2 production allow researchers to precisely calculate an individual’s metabolic rate.  From the O2 and CO2 readings, researchers can calculate calories burned and what type of fuel (carbs/fats) was used to burn them. Urine is collected to assess protein oxidation.

Metabolic chamber studies have demonstrated how flexible the body is with respect to metabolism. One reporter wrote, for instance, that they’ve debunked the idea that ketogenic diets (high-fat/low-carb) cause the body to burn more fat than high-carb diets.

Energy is burned in our body in three ways. It turns out that simply staying alive is pretty energy intensive. Most of the calories we burn (65-80%) are used simply to keep our body running (basal metabolism). Digestion is no walk in the park either; digesting our food takes up about 10% of the calories we burn in a day, with physical activity accounting for the remainder (10-30%).

If ME/CFS patients’ metabolic production and ability to produce energy is altered by exercise – as Workwell’s and Dr. Keller’s tests suggest it is – that will hopefully be picked up by the metabolic chamber.

Robert noted that if they can pair the findings from the metabolic chamber – which is measuring the metabolic effects of exercise – with the Seahorse tests- which are measuring energy production on the cellular level, they may really be onto something.

Brain Scan

The functional MRI – which Robert said was combined with a cognitive test – will assess the impact of exercise on a) cognitive functioning and b) brain functioning. A similar study by the CDC suggested that exercise negatively impacted both cognitive and brain functioning.

People who do cognitive tests tend to improve the more they do them but not in this case – not in people with ME/CFS after exercise.  Familiarity did not breed more competence. Despite doing the tests multiple times, the people with ME/CFS did worse and worse on them after exercise and the brain scans indicated why. Exercise had knocked out one area of the brain devoted to sustained attention causing the brain – in a mostly futile attempt to compensate – to increase activity in other parts of the brain (devoted to executive functioning).

A Chronic Fatigue Syndrome Brain on Exercise – Not a Pretty Sight

The end result was that people with ME/CFS expended more effort during the cognitive test and yet did worse. By the end of the test they were making about double the errors of the healthy controls.

rTMS Test

motor cortex

The rTMS test appeared to be designed to stimulate Robert’s motor cortex to activate his muscles.

The repetitive transcranial magnetic stimulation (rTMS) test proved enormously interesting but physically draining.  Robert reported that in a process that took hours, data from a previous fMRI was used map the exact location of his motor cortex in order to stimulate the muscles of his right hand/fingers.  The goal was apparently to determine the speed at which the signal traveled from the brain to the muscle of his finger before and after exercise.  A time delay after exercise would presumably indicate that exercise had interfered with the ability of the motor cortex to activate the muscles.

A 2003 study, in fact, suggested that reduced muscle recruitment due to reduced motor cortex output was occurring in ME/CFS. The motor cortex, it turns out, plans our movements in advance. The study, titled “Deficit in motor performance correlates with changed corticospinal excitability in patients with chronic fatigue syndrome“ suggested that problems in the “motor preparatory areas of the brain” might be hampering physical movements in ME/CFS. It has never to my knowledge been followed up on.

rTMS has relieved pain in fibromyalgia but it had the opposite effects in Robert. He wasn’t clear whether it was the effects of the rTMS or the rigors of setting up the test itself or both which triggered for him what turned out to be an extraordinary bout of PEM (post exertional malaise). The 2 hours it took – sitting up – to get the electrodes correct was in itself draining. (He suggested that they use a reclining chair for future patients if possible.)

At the end of test Robert felt exhausted and experienced transient vertigo, auditory disturbance, headache and sensitivity to light and noises.  His nurse was shocked at how poorly he looked.  He’d mentioned the documentary Unrest to her the day before. After seeing the movie, she said she could better appreciate what he was going through. (Hopefully she knows that watching the film will get her continuing medical education (CME) credits)

The rTMS test proved immediately much more exhausting than the exercise test, the effects of which took a day to kick in. The rTMS specialist/researcher was surprised at the effect the test had on Robert and its cause is unknown. Was it the long preparatory period or the activity of the rTMS machine on the muscle activation pathways or both?  It’ll be fascinating to see how other patients fare.

Robert was also tested for small fiber neuropathy via skin biopsy, underwent a post exercise lumbar puncture and quadricep muscle biopsy.  The possibility of integrating the brain scan, cerebral spinal fluid, Seahorse and metabolic chamber results after exercise – not to mention the immune tests – is an enticing one for sure.

NIH intramural ME/CFS study data collection

The study, which is going to generate an enormous amount of data, is still several years away from completion.

Plus there are the muscle biopsy results. Robert’s experience of a rather hefty muscle biopsy suggests that the NIH is not stinting on this area – which Dr. Nath believes may tell us much about ME/CFS.

Plenty of rest periods were provided during the study but at times the testing was lengthy, and the study, predictably, ended up being a rather grueling seven days for this courageous but very disabled ME/CFS patient. Participating in it wasn’t easy but the fact that Robert, even with his abysmal level of functionality, made it through it and recovered, was a good sign. Robert said he was touched by a chaplain who stopped by to see how he was doing.

He’s stayed in touch with the investigators from time to time alerting them of developments in the ME/CFS field.

Participating in the Study

The NIH needs more participants. If you’re interested in helping to further ME/CFS research by participating in the study, check out the study criteria below.

All participants must be 18-60 years old and have at least a 7th grade education. People whose ME/CFS started after an episode of infection and who have severe symptoms lasting from 6 months to 5 years are eligible to participate in the study.

Find out how to participate here.

Learn more about the Intramural Study

Dr Nath Talks on the ME/CFS NIH Intramural Study

Dr Nath Talks on the ME/CFS NIH Intramural Study

It looked like we were going to be late … again. It was pouring cats and dogs as we eased the van around tangled web of streets that is the NIH campus scanning glumly at the rain-obscured buildings. Even our guide on the phone seemed to be lost.

It had been a wild 12 hours. The night before, reaching up to turn on the fan on my brother’s porch, I’d let loose a rather large bug which tumbled into my eye. Howling with pain I stumbled off to the bathroom where I managed to wash it out – leaving my eye reddened and swollen. The next morning, my eye still swollen, my partner insisted I see an eye doctor.

 

NIH

Getting to Dr Nath’s office proved to be a challenge

To our surprise we found somebody. The problem was was that his office was right in the heart of downtown Washington DC. – where parking is scarce and traffic cops take their jobs very seriously. Finding no parking we stopped in a loading zone across from the doctor’s office, hoping that the big yellow van with it’s solar panels, Nevada license plate and all would for the next 15 minutes be taken for a loading van –

After being assured the appointment would be short, I dashed inside where I was  bombarded by frantic calls from my partner (who does not drive the van). She had immediately been accosted by first one then another traffic cop.

After seeing the doctor who informed me (for $250 dollars) that insects in the eyes almost never cause problems (but who did give me drops) I dashed back out to the van to find my now none-too happy partner.

We sped off in the rain – still seemingly on time for the appointment with Dr. Nath. Hauling up to the NIH we tried no less than three entrances – only to be turned away at each them (our oversize vehicle thwarting one attempt) – and directed to the next. Finally, as our appointment time came and went, we found the right entrance – for, ironically, delivery vehicles.

After going through an extensive (and time-consuming) security check we headed off into the labyrinth that is the NIH clutching small hard to decipher maps and immediately got lost. The  minutes continued to tick by and rain strengthened into a deluge and eventually we managed to steer onto the right street. Our guide, still on the phone, told us to stop, we jumped out of the car and looked up, rain pouring down, at a steep, muddy climb.

Five minutes later – 45 minutes late for our hour appointment, we strode, soaked and bedraggled into Dr. Nath’s office. He immediately set us at ease, and with his next appointment running late stayed overtime with us. We were there to talk about the NIH Intramural ME/CFS study.

The NIH Intramural ME/CFS Study

Dr. Nath informed us that the applications to be in the NIH Intramural ME/CFS study have been gratifyingly robust.  Dr. Nath noted that it was entirely possible that this is the most rigorously examined patient group ever assembled for a study.

Dr. Nath

Dr. Nath is leading the study. He has been around. He received his MD degree from Christian Medical College in India in 1981, completed a residency in Neurology from The University of Texas Health Science Center in Houston, did a fellowship in Multiple Sclerosis and Neurovirology at the same institution, and then another fellowship in Neuro-AIDS at NINDS.

Then it was up to Canada, where he held a faculty position at the University of Manitoba (1990-97), and then he was at The University of Kentucky (1997-02). In 2002, he became Professor of Neurology and Director of the Division of Neuroimmunology and Neurological Infections at Johns Hopkins.

in 2011, he became the Clinical Director of NINDS, the Director of the Translational Neuroscience Center, and Chief of the Section of Infections of the Nervous System. His research focuses on understanding the pathophysiology of nervous system infections and their outcomes, and the development of new diagnostic and therapeutic approaches for these diseases. He’s heavily involved in HIV research, the role endogenous retroviruses play in neurological diseases, and “undiagnosed neuroimmune and neuroinfectious diseases”.

He recently wrote a paper on Herpes Viruses, Alzheimer’s Disease, and Related Dementias: Unifying or Confusing Hypothesis?, which examined what role herpesviruses might be playing in dementia.

The NIH Intramural Chronic Fatigue Syndrome Study

The study takes place in two parts: a one week part which further assesses the potential participant and another one week section which measures a wide variety of parameters before and after an exercise test.

Requirements for entry are high, however, and not often met. You might say that many have been called – or rather have called – but few have been chosen. That was OK with Dr. Nath. “We need,” he explained, “to make sure that we’re studying the right population. That’s the best way to get to the answer, and then it’ll be broadly applicable.”

The response has been excellent.  Many people are traveling to participate, and they’re coming from all over. The NIH is even getting interest from people in other countries.

As of Dec. last year, 337 people had inquired about the study. One hundred and seventy-three were quickly screened out, and 164 participated in phone interviews. One hundred and twenty-seven made it to the medical record assessment stage.

Multiple reasons thwarted would-be participants from participating in the study.  The study required onset within 5 years which was triggered by infection. One-third had had the disease for too long, 20% had no evidence of infectious process (doctor’s records are required), 9% were too sick to travel, and just 3% were unwilling to have a lumbar puncture.

community ME/CFS

Nath noted that the ME/CFS community was very motivated to be in the study

The researchers were surprised at the last two figures. They expected, based on their experience from past studies, much higher percentages of people who were too sick to travel or unwilling to have a lumbar puncture. Dr. Nath well knows how difficult it can be to get people to participate in a study, but that’s not a problem here. Calling the numbers “very good”, Dr. Nath said the ME/CFS community was clearly “very motivated to participate in the study”.

It is not an easy study! It’s a two-part, two-week plus study on a population, which studies suggest, has the lowest functionality of any disease. The study includes a lumbar puncture, a maximal exercise test, several nights in a metal box (metabolic chamber), tilt table test, muscle biopsy, brain scans, lengthy neuropsychological tests and scads of blood tests. Every part of you is going to be probed.

Plus, you have to provide your entire medical history, get interviewed several times, and then, most likely travel.

Dr. Nath said he looked at the study – which is clearly larger and more intensive than most  – and said, “who is going to enroll in this study?” Laughing, he joked that, “I wouldn’t volunteer on my own study!” He was afraid no one was going to show up!  Instead he said the patients were very willing to undergo all the tests and are grateful for it.

Recruitment has been good, but as with any study, Dr. Nath said, it was high at first, and now it’s tailed off. As of March of this year, 19 ME/CFS patients and 21 healthy controls had completed the first phase of the study, and six people with ME/CFS and 7 controls had completed phase II.

Thus far, then, about half the projected participants (n=40 ME/CFS; 40 healthy controls) have gone through the first week of the study and about 15% have completed the entire study.

Quite a few people with autoimmune disorders have shown up during the filtering out process. Nath suggested that could be an interesting cohort to study on its own.  He’s also found quite a bit of head injury and loss of consciousness – which makes MRI and brain scans difficult to assess – and people with seizures and strokes. Interestingly, bnly one person had had a diagnosis of major depression….

High Percentage of Rare Diseases 

It’s a small sample set but it’s remarkable how many people participating in the first week were diagnosed with a rare disease. In something of a testament to the thoroughness of the study, almost third of week one participants (6/19) were found to have a rare disorder which the researchers believed was probably causing their symptoms and dismissed from the study. One appeared to have Parkinson’s Disease, another a neurological disease and I’m unsure of the others.

The study was designed to catch these people.  In fact because ME/CFS is something of a wastebasket diagnosis it went to extra lengths to ensure it was really studying ME/CFS.  Plus Dr. Nath reported that neurological diseases are inherently hard to diagnose anyway.  It is not unusual for people with multiple sclerosis, Parkinson’s, etc to be misdiagnosed with some other disease initially.  Plus, the opposite can happen (and has happened in ME/CFS) with some patients being misdiagnosed with M.S. for many years only to find later that they have some other immune disorder.

Big Data

They are gathering lots and lots of data – which brings its own problem. The study includes two different brain scans, blood, saliva, urine and stool samples, exercise data, tilt table data, spinal taps, Seahorse data, metabolic room data, cognitive testing, muscle and skin biopsies, and I’m probably missing some. I asked Nath, how will they able to integrate all this disparate data?

rare disorder chronic fatigue

Rare disorders are popping up at a high rate in the study group

Nath agreed that it was a challenge, but noted that that kind of challenge is a pretty common challenge now. Some of the really big Alzheimer’s and Parkinson’s studies contain thousands of individuals, each of whom has done thousands of tests. Computational biology has become a major part of medical research.

Google, not surprisingly, is collaborating with the NIH to create better ways to analyze data. Many of the discoveries in medicine today, Nath said, actually occur as breakthroughs in physics; MRI and CT scans, for example – came from physics.

Their general hypothesis is that an infection triggers brain and immune system issues (ranging from persistent immune activation to immune dysregulation) that stay stuck.  They don’t believe the nature of the infection is particularly important.

Check out a disease Nath believes could prove a model for ME/CFS

East African Disease Informs Nath’s Search for the Cause of ME/CFS

No Preliminary Findings Yet

Nath was unable to give me any preliminary findings. One reason is that they are storing samples so they can run them all at the same time. Another is that, echoing Ron and Mark Davis’s thoughts, they don’t want to even try to come up with hypotheses yet. They simply want to gather more and more data.

Making a conclusion on the basis of small samples is, Nath said, the kiss the death. They will not even try to interpret their findings until about half the study is done.

If, when they get to the end of the study, they see trends but don’t quite have a significant result, they’ll do sample size calculations to determine how many more patients they’ll need to see to get to statistical significance. If the calculation says do another 10 patients, they’ll probably expand the study to do 12 more. If the calculation says do another 100 patients, that’s too much.

They’re preventing another kind of bias by recoding the samples, so the analyst doesn’t know which are from patients and which are from controls.

The Study

Brian Vastag’s visit raised the issue of mitochondrial problems. Nath believes studying the muscle itself may be more important than assessing mitochondrial problems using the blood, and added muscle biopsies to the study. The muscle biopsies will be tested for DNA analysis, structural issues, and staining for various kinds of cells.

The Open Medicine Foundation and Ron Davis apparently believe likewise. They’ve pumped a million dollars into an ME/CFS Collaborative Research Center at Harvard lead by Ron Tompkins which will focus on figuring out what is going on in the muscles.

muscles ME/CFS

Dr. Nath believes the muscles could tell us much about ME/CFS

Because lots of patients have autonomic symptoms, the NIH is doing tilt table tests. Once those turn out positive, Nath said, the next question is why the autonomic nervous system problems are present. They’re doing small fiber neuropathy skin tests and examining the heart, peripheral nerves, adrenal glands, and sympathetic nervous system functioning.

I asked him if there were any surprises, and there were.  As Robert’s story will show, the NIH doesn’t seem to be prepared for the level of devastation ME/CFS can wreak in a relatively young group of patients.

Nath said his personal contact with the patients has led him to develop a real appreciation for the disease. These patients, he said, “are devastated”. Whether or not this study finds a cause, the reality, Nath said, is that the lives of the study patients are “totally messed up.” Then he made an important point.  Seeing the patients in the flesh naturally causes him and other researchers to develop additional empathy for them and “another level of appreciation” for them and their disease.

It was clear that just by being there and exposing the researchers and doctors at the NIH to this disease, the participants in the study are making a difference.  The lengths to which some patients are going to participate in this study are amply illustrated by Robert’s story.

Participating in the Study

The NIH needs more participants. If you’re interested in helping to further ME/CFS research by participating in the study, check out the study criteria below.

All participants must be 18-60 years old and have at least a 7th grade education. People whose ME/CFS started after an episode of infection and who have severe symptoms lasting from 6 months to 5 years are eligible to participate in the study.

Find out more here.

A former doctor on his experience going through the NIH’s intramural study

A Former Doctor Goes Through the NIH’s ME/CFS Intramural Study

The Brainstem, Vagus Nerve, Neuroinflammation and Chronic Fatigue Syndrome: The VanElzakker Way

In 2013, Michael VanElzakker produced one of the most intriguing hypotheses to date in ME/CFS. His Vagus Nerve Hypothesis proposed that an infection/inflammation near the vagus nerve was causing it to send an unending stream of messages to the brain, telling it to essentially shut the body down by producing fatigue, pain and other symptoms. Since then, he’s been particularly interested in the connection between the vagus nerve, the brainstem and the ME/CFS.

He’s not the only one interested in the brainstem. In 2019 once his brainstem compression was alleviated, Jeff completely recovered from his severe ME/CFS, POTS and MCAS. Since he published his story over a dozen people have been diagnosed with craniocervical instability – a condition which compresses the brainstem.

In this critical review paper, VanElzakker et. al. pick apart some of the research done and provide a guide to successfully getting at the brainstem and other regions of the brain. It’s called a “Critical Review” and is critical, indeed. It finds many past ME/CFS studies wanting, but then points a way to a better possible future. If brainstem problems play a role in ME/CFS these researchers demonstrate how to get at them.

One Theory To Explain Them All? The Vagus Nerve Infection Hypothesis for Chronic Fatigue Syndrome

Neuroinflammation and Cytokines in Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS): A Critical Review of Research Methods.  Michael B. VanElzakker, Sydney A. Brumfield and Paula S. Lara Mejia. Front. Neurol., 10 January 2019 https://doi.org/10.3389/fneur.2018.01033 https://www.frontiersin.org/articles/10.3389/fneur.2018.01033/full

First, VanElzakker et. al. examines one of the sacred cows in the chronic fatigue syndrome (ME/CFS) community – the preferred term for so many: myalgic encephalomyelitis (ME), which refers to muscle pain (myalgia) related to central nervous system inflammation (encephalomyelitis).

While muscle pain is common, it’s not universal. Even people with severe ME may not report pain.

Still, the core part of the definition deals with central nervous system inflammation – a description that, with the emergence of the 2015 Yakatomi and the 2019 Younger studies, seems more and more likely to stick. (A 2018 PET scan study also found neuroinflammation in fibromyalgia as well.)

The idea that inflammation plays a key role in this illness makes sense, given the infectious trigger so commonly (but not universally) found. The authors are just a few among many (Avindra Nath, Jarred Younger, Andrew Lloyd and others) who believe that an infectious event has triggered changes in the brain that are producing fatigue, pain and other problems in ME/CFS.

They point to three ways an infectious trigger could produce central nervous system inflammation in ME/CFS:

A) immune factors (e.g. cytokines) triggered by the infection could get transported across the blood-brain barrier (BBB) that protects the brain. The normally taut blood–brain barrier makes blood-borne infections of the brain rare, but it can, like the gut, become leaky in inflammatory states, allowing immune factors and pathogens entry. Once in the central nervous system, they could trigger a large inflammatory response, or

B) High concentrations of immune factors could allow pathogens to passively diffuse across the BBB, or

C) Immune factors in the blood could trigger the vagus nerve to send signals to the brainstem and brain, which then sparks an inflammatory response.

It’s the last option that primarily concerns these authors. VanElzakker is the author of the Vagus Nerve Hypothesis, which proposes that an infection/inflammation near the vagus nerve is causing it to send an unrelenting stream of signals to the brain, telling it to produce the flu-like symptoms that constitute “sickness behavior” (withdrawal to bed), which isolates infected people from the community and keeps them from spreading an infection.

The largest nerve in the body, the vagus nerve transmits sensory, autonomic, immune and other signals to the brainstem – making it potentially a key player in a possible neuroinflammatory disease like ME/CFS.

Studies indicate that inflammation in the periphery tends to produce a mirror inflammatory response from the immune cells (the glia) in the brain. Even small levels of cytokines in the periphery or body have the potential to activate the chemoreceptors in the vagus nerve, which then activate the immune system in the brain.

That brain activation, interestingly, tends to occur in regions (basal ganglia, limbic system organs (amygdala, hippocampus and hypothalamus), anterior cingulate cortex, prefrontal cortex, and thalamus), which studies suggest are also involved in ME/CFS.

The Brainstem

brainstem

The brainstem regulates many vital functions in the body

The authors believe the brainstem (which, as it name implies, is found at the very base of the brain, above the termination of the spinal cord), could play a key role in chronic fatigue syndrome (ME/CFS) for four reasons:

  1. Immune signals from the vagus nerve to the brain travel through the brainstem.
  2. The brainstem is dense with mast cells, and mast cell activation syndrome (MCAS) appears to be common in ME/CFS.
  3. The brainstem regulates autonomic nervous system functioning – a common trouble area for ME/CFS and related disorders.
  4. The brainstem also regulates immune functioning; in particular, it triggers an anti-inflammatory response that should limit the inflammatory response.

Whether caused by a structural problem (as in Jeff’s case), inflammation or an infection, the brainstem is a centrally placed brain component that produces many of the issues in ME/CFS.

Could Craniocervical Instability Be Causing ME/CFS, Fibromyalgia & POTS? Pt I – The Brainstem Series

Seeing the Brainstem in Chronic Fatigue Syndrome (ME/CFS)

Consistent inflammation of the brainstem has not, however, been found in ME/CFS. The authors argue, though, that researchers have rarely used the right kind of imaging needed to investigate this.

The most commonly used method for measuring inflammation in the brain involves measuring the 18kD translocator protein (TSPO) with a PET scan. This protein is produced when the immune cells of the brain – the microglia – become activated. Because the microglia are the chief producers of inflammation in the brain, the TSPO provides a reliable way to indirectly measure neuroinflammation and its effects.

The Nakatomi Study

Nakotomi’s small ME/CFS study using TSPO made a big splash in 2014.   Tony Komaroff called the finding of central nervous system inflammation the most important study in decades. Five years later, Van Elzakker et. al. called it “important” and potentially “groundbreaking”. The study used TSPO imaging to find widespread neuroinflammation, particularly in the areas leading from the brainstem to the thalamus.

While the authors regard Nakatomi’s study as potentially groundbreaking, the study is not without significant issues. The authors, in fact, seemed a bit shocked that Nakatomi found as many effects as he did, given the techniques used.

The neuroimaging techniques Nakatomi used (and which most researchers use) were not designed to address brainstem inflammation. Nakatomi used a spatial “registration” technique that aligns the image on the neocortex or upper part of the brain. This kind of alignment is typically done because researchers tend to focus on the upper, “higher” functioning areas of the brain. It can, however, impair the sensitivity of imaging done on the lower, more densely packed, primitive areas of the brain, such as the brainstem, and lead to false negatives.

The PK-1195 tracer

Nakatomi also used an older tracer (PK-11195) which does not penetrate deeply into the brain and can bind to unintended elements in the brain. Differences in blood-brain barrier permeability between the ME/CFS patients and healthy controls – a distinct possibility – could have confounded the results, as well. Nakatomi’s use of the cerebellum as a kind of baseline measure could have introduced further issues if problems with the cerebellum (another possibility) exist in ME/CFS.

Plus, the hypometabolism believed present in ME/CFS could have resulted in lower amounts of the tracer being metabolized than usual – causing higher amounts of the tracer to reach the brain – and producing a false positive. Because exercise may affect how much of the tracer is taken up into the cells, Nakatomi’s use of healthy, non-sedentary controls instead of sedentary controls introduced another issue.

Finally, because the brainstem actually pulses with every heartbeat, that movement needs to be accounted for – and usually isn’t in ME/CFS studies.  The very small but important nuclei in the brainstem are also often not picked up with the standard imaging techniques used in ME/CFS research.

Nakatomi’s study results make sense given what we know, and were given a sort of validation by Jarred Younger’s recent results using thermal mapping – a new technology – but we need more validation.

The takeaway is that the brainstem – because of the role it plays in autonomic nervous system functioning, immune regulation and the transmission of motor signals – could play a major role in ME/CFS, but is essentially, according to these authors, still something of a black box.

Barnden’s Brainstem – the Australian Study

It’s not completely a black box, though. Researchers using other techniques have found evidence of brainstem problems in ME/CFS. Barndem in Australia, in particular, has done a series of MRI studies which have found striking brainstem issues in ME/CFS.

(During his talk at the 2019 Emerge conference, Barnden noted how he had to shift his MRI to avoid the alignment problem (that VanElzakker mentioned) which prevented him from getting a good image of the brainstem. )

One study found that reduced brainstem grey matter volume – suggesting that damage to the neurons in the brainstem had occurred – was correlated with autonomic nervous system problems in ME/CFS.

Barnden brainstem damage ME_CFS

Using the right imaging approach Barnden found extensive evidence of damage to the neurons (myelin) in the brainstem. (From the 2019 Emerge Conference Livestream)

Another study finding of impaired communication from the brainstem nuclei to other nuclei in the brain suggested the same, and found increased signs of myelination in the sensorimotor cortex of the brain.  Barnden proposed that decreased signaling from a damaged brainstem provoked a compensatory increase in myelination in the sensorimotor region as it bulked up to try to understand the limited signaling coming from the brainstem. The impaired brainstem-sensorimotor connection might be, Barnden thought, impacting motor functioning in ME; i.e. the ability to carry out physical activity.

Signals to move muscles pass from the motor cortex to the sensorimotor cortex down to the thalamus and then through the brainstem to the muscles. (Signals from the muscles to the brain pass up through the same pathways.) Barnden proposed that the movement problems in ME/CFS could start with the brainstem’s inability to properly relay signals to the motor cortex to activate the muscles.

Barnden’s most recent brainstem study validated the idea that inadequate communication between the brainstem nuclei and other nuclei in the brain, including the vasomotor region, hypothalamus and prefrontal cortex, was affecting autonomic nervous system functioning in ME/CFS.

Other Kinds of Brain Scans

Other kinds of brain scans, such as magnetic resonance spectroscopy (MRS), can pick up signs of neuroinflammation. Although almost 10 MRS studies of the brain in ME/CFS have been done, VanElzakker et. al. report that a clear and consistent picture of metabolite alterations in the brain has yet to emerge.

They believe that’s due largely to a common theme in medical research, found in this disease in particular – lack of standardization. Different diagnostic criteria, different types of healthy controls, different brain regions examined, and different metabolites targeted make it difficult to present a clear picture of the metabolic alterations in the brains of people with ME/CFS.

The Japanese Take

The Japanese probably couldn’t agree with Barnden more. Their studies indicate that, as the healthy controls became more fatigued, two core regions – both of which communicate with the brainstem ( the prefrontal cortex and the anterior cingulate cortex) – shut down.

As these regions begin to shut down, control of autonomic functioning becomes lost.  In particular, the ability to activate the parasympathetic nervous system (i.e. the vagus nerve) and tone down the sympathetic nervous system activity, is lost.

The Japanese believe a breakdown in what they call the facilitation system in the brain has occurred.  As we become fatigued, the facilitation system jumps in to increase the signals coming from the primary motor cortex to the muscles. This increased “drive” from the motor cortex prompts the muscles to work harder and activates more and more of them so that activity can proceed.

Fatigue – the Japanese Way: A Chronic Fatigue Syndrome Perspective

So long as new, fresh muscle fibers remain to be recruited, the activity can continue.  If no muscle fibers are left to be recruited or if the brain has a problem recruiting new muscle fibers, fatigue sets in.

A 2003 study suggested that reduced muscle recruitment due to reduced motor cortex output was indeed occurring in ME/CFS. That study suggested that, “… changing motor deficits in CFS has a neurophysiological basis [which] … supports the notion of a deficit in motor preparatory areas of the brain”.  That study titled, “Deficit in motor performance correlates with changed corticospinal excitability in patients with chronic fatigue syndrome“, to my knowledge was never followed up on.

Fatigue Explained? Japanese Assert Brain Damage Causes Fatigue in Chronic Fatigue Syndrome

Conclusion

Several studies suggest significant brainstem issues may be present in ME/CFS. Problems with the brainstem could produce everything from autonomic nervous system problems to immune issues to problems with movement.

The authors critique past brain imaging studies and provide a “how to” guide to assess the brainstem in ME/CFS. Barnden’s Australian brainstem studies suggest that when done correctly, MRI imaging studies may indeed find extensive damage is present in ME/CFS including evidence of brainstem neuron demyelination, a compensatory remyelination in parts of the brain the brainstem connects with, and lastly, a reduced connectivity between these regions.

VanELzakker et. al.  assert that future imaging studies that focus on the specific functional connectivity pathways in the brain which are activated by inflammatory processes should be able to capture the neuroinflammatory processes occurring in ME/CFS.  (Two of the three pathways they cite include the brainstem.) The thalamus’s role in sensory stimuli activity presents another fruitful pathway to assess.  Lastly, the authors suggest that researchers target the nucleus of the solitary tract (NTS) where the vagus nerve enters the brainstem.

With help from an ME/CFS donor, VanElzakker has been employing brain imagining techniques to assess the brainstem in chronic fatigue syndrome (ME/CFS). He will be speaking at the NIH ME/CFS Conference in Baltimore in April.

One Theory To Explain Them All? The Vagus Nerve Infection Hypothesis for Chronic Fatigue Syndrome

Catching ME/CFS in the Act: The Collaborative on Fatigue Following Infection (COFFI)

It sounds like a great idea – combine all the post-infectious fatigue studies together into one database in order to find answers to one of the biggest questions in ME/CFS – why do some people stay ill after an infection while others recover?

infection - chronic fatigue

Every major infection has provoked a similar response – a significant number of people become chronically ill.

COFFI (Collaborative on Fatigue Following Infection) incorporates no less than 9 studies that have examined post-infective fatigue or illness. The Dubbo study – pioneered by Andrew Lloyd and funded by Australian Health Agencies and the Centers for Disease Control (CDC) in the U.S., still in some ways the best study – started it all off.

The most dramatic conclusion of the first Dubbo study was that somewhere around 10% of people exposed to a serious infection remained ill six months later. Remarkably, the kind of infection – viral or bacterial – didn’t matter. It seemed that being exposed to any serious infection left one at risk for a prolonged fatiguing illness.

Since the Dubbo studies began, eight other post-infectious cohort studies have finished up or are underway. The largest of these are the four Chicago cohort studies (about 1000 participants) under the direction of Ben Katz and Lenny Jason, which have been examining infectious mononucleosis college students for almost ten years. There’s also campylobacter gastroenteritis (n=600), Legionnaires disease (n=190), and Ross River Virus (n=60) cohorts. All told, about 3000 people have participated in 9 studies which have examined people who failed to recover from an infection.

COFFI believes that susceptible individuals develop prolonged fatigue after infection because of biological (immune system, autonomic nervous system, etc.), behavioral and/or environmental effects, which produce alterations in neurobehavioural, cardiovascular and/or immunological systems. The goal of the collaborative is to elucidate what went wrong in those with post-viral (and bacterial) illnesses.

On the face of it, the collaboration holds great promise. How better, after all, to learn about how an illness develops than to capture it in its earliest stages?

The Post-Infectious Illness Group

Different flavors of post-infectious illness exist. One set involving diseases like acute disseminated encephalomyelitis and Guillain-Barre Syndrome produces very dramatic symptoms (paralysis, coma) and is studied. The other produces less dramatic symptoms (fatigue, cognitive problems, PEM) etc., but despite the tremendous functional hits seen, has mostly skated under the scientific establishment’s radar.

The studies that have emerged in the second group look like the kind of studies you would expect from a niche topic. They tend to be underfunded, focus on more easily and cheaply assessed factors, are often light on biological analyses, and sometimes focus on behavioral factors.

Nevertheless, some foundational findings have emerged. First – any serious infection is going to incapacitate a significant subset of those afflicted. The results have been remarkably consistent across types of infectious onset, with most showing from 9-13% of those encountering a serious infection of any type are still ill at six months and 7-9% remain ill a year later.

That’s obviously not a small number of people.

Lloyd, the senior author of the collaborative, has enrolled a mishmash of partners. They include biologically oriented members (Ben Katz, Renee Taylor, Ute Vollmer-Conna, Knut-Arne Wensaas, Jeannine L.A. Hautvast), some in-betweener’s (Brun Wyller, Dedra Buchwald, Renee Taylor) and some behaviorists (Peter White, Esther Crawley, Gabrielle Murphy, Rona Moss-Morris).

The Epidemiological Efforts

Giardia

The Bergen Giardia studies demonstrate the funding woes present in this field. They’ve succeeded in documenting high rates of ME/CFS, chronic fatigue and/or irritable bowel syndrome (IBS) years after an extended Giardia outbreak in Norway.  The studies have established that the outbreak has had a significant health impact on a substantial number of people – an important finding for sure – but it’s been unable, until recently, to delve into any biological factors. (A genetic study is underway.)

The Biopsychosocial Efforts

Moss-Morris’s work shows that cognitive behavioral therapy (CBT) has moved into clearly defined biological illnesses such as MS and renal disease. She’s managed to study the behavioral aspects of fatigue and/or conducted CBT trials in no less than five diseases – ME/CFS, IBS, multiple sclerosis, renal disease and cancer. (The MS CBT trial was deemed successful.)

Moss-Morris assessed epidemiological and biopsychosocial factors in people who became ill following a campylobacter infection (food poisoning). Ironically, that study suggested that those who tried hardest to ignore or push past their illness (e.g. who felt “I must not let this get the better of me” and who engaged in all-or-nothing behavior) were most likely to get ill. (So much for the malingering hypothesis).

chaos

The biopsychological studies have failed to provide consistent theme

Psychologist Peter White must have been chagrined to find that his Bart cohort failed to indicate that mood disorders or negative life events contributed to a “fatigue syndrome” after an infection.

The results of Buchwald’s 2000 infectious mononucleosis study must have flummoxed everyone.

It suggested that a greater number of life events more than six months before the illness began and increased family support were predictive of those who remained ill.

The Q fever studies ended up with a similarly hard to understand mix of factors. Female gender, being younger, having a pre-existing health condition, and being hospitalized in the previous 3 months might make some sense, but why would consuming no alcohol and using medication contribute to a prolonged illness?

The Qure study found that long-term doxycycline treatment utterly failed to move the needle on the illness; i.e. a persistent bug is not responsible.  CBT, on the other hand, improved fatigue and symptoms somewhat but completely failed in the most important measure – improving functionality. (By reducing stress, behavioral therapies should provide some symptom reduction…)

The lack of a recognizable theme suggests that the biopsychosocial results are not getting at the root of anything.  If the goal is illness eradication, researchers need to dig into the biology, and biological efforts have indeed achieved better results.

Biological Efforts

The studies that have dug deeper into biology appear to have been more successful.  Blood tests in the Dubbo studies suggested that pathogen persistence was not the issue: in every case the pathogen appeared, at least, to have been vanquished.

The results of the Qure study on the effectiveness of long-term doxycycline treatment in those with prolonged Q fever suggested the same: it found that the standard treatment for the disease had no effect at all on those who remained ill.

Nor did immune activation over time – as measured by cytokine levels – appear to cause disease persistence in the Dubbo group.

The only risk factors identified occurred early in the illness. Higher levels of cytokines and symptom severity early in the illness appeared to set the stage for a prolonged illness. This suggested that the bug – whichever bug it was – did its damage early and then disappeared.

Genetic studies then suggested a reason why. Immune gene polymorphisms were found in this group which predisposed them to a heightened immune response when confronted with a pathogen.  With three studies confirming and extending that finding, it seems solid. It appears that people with polymorphisms in specific immune genes that heighten the inflammatory response are more likely to become and stay ill.

consistency

The biological studies have provided a more consistent theme of immune activation and autonomic nervous system activation.

The ongoing Chicago infectious mononucleosis studies have dug a bit deeper biologically and uncovered some interesting findings.  Autonomic symptoms and early illness severity were predictive of a prolonged illness (while perceived stress, stressful life events, family stress, difficulty functioning and attending school, and psychiatric disorders were not).

Six months of illness resulted in lower oxygen consumption and reduced peak oxygen pulse; i.e. problems utilizing oxygen – something that Hanson’s latest metabolomic study and others suggested may be happening. (The authors called this “reduced fitness” and “efficiency of exercise.”).  Plus, a network analysis was able to diagnose 80% of ill patients using immune factors, and at six months autonomic nervous symptoms stood out. The analysis suggested a powerful pro-inflammatory immune state persisted for as long as 24 months after the initial onset.

The new “Dubbo studies” (“The Sydney Infectious Outcomes Study (SIOS)) have found an early reduction in heart rate variability, suggesting autonomic nervous system involvement.

In contrast to the biopsychosocial-oriented studies, a theme may be emerging in the biological studies: immune activation and autonomic nervous system problems early, resulting possibly in problems with oxygen utilization, with autonomic nervous system problems persisting.

Wyller’s Weird Results Or Why a Poor Study is Worse Than No Study at All

Many of the post-infective studies have been confined to charting epidemiological factors. Only the initial Dubbo study and the Katz/Taylor Chicago studies have tried to dig deeply at all into biological factors. Even then the scope of the studies has been limited.

Brun Wyller’s CEBA studies (Chronic Fatigue Following Acute Epstein-Barr Virus Infection in Adolescents) appeared at first glance, to fix that. The three studies analyzed 149 factors including early illness severity, immune factors, neuroendocrine stress response, cognitive functioning, emotional disturbances, genetics/ epigenetics of candidate genes, personality traits, and critical life events during and after infectious mononucleosis (IM).

Steps Per Day

The first CEBA study (Lifestyle factors during acute Epstein Barr virus infection in adolescents predict physical activity six months later) assessed the effects of the 149 factors on the number of steps taken per day at six months in 200 individuals. None of the markers of infection or immune response studied affected activity levels.  (Nor did any psychological factors).

Instead, three factors – none of which showed up previously in the post-infectious studies – did. Baseline physical activity (steps per day), substance use (alcohol and illicit drugs), and human growth hormone were associated with reduced steps per day after six months. (Notice the opposing substance use results: low alcohol use was a risk factor for post-Q fever illness, while increased alcohol/substance use was a risk factor for post-infectious mononucleosis illness).

The results suggested that sedentary individuals with low HGH levels who were abusing alcohol/drugs and who became ill with IM are predisposed to be, guess what, more sedentary than usual six months after coming down with infectious mononucleosis.

That’s among the most underwhelming and just weird results I’ve ever seen, and one wonders why Wyller bothered to publish it.

Predictors of Chronic Fatigue

Predictors of chronic fatigue in adolescents six months after acute Epstein-Barr virus infection: A prospective cohort study.

Another study of Wyller’s cohort charted biological factors against fatigue at six months. The main finding that a bunch of symptoms (sensory sensitivity, pain severity, functional impairment, negative emotions) were associated with increased fatigue simply stated the obvious. The more fatigued a person was, the more negative emotions they had (what a surprise!), the more functionally limited they were (!!!!), and the more pain they were in (stunning!), etc.

The fact that viral load had no predictive value was in line with past studies. The slightly increased plasma C-reactive protein found (Wyller suggested it was caused by negative life events) and reduced plasma vitamin B12 levels were the only two biological factors that stood out.  Neither will move this field forward significantly.

Predictable Results?

So how did Wyller get such pitiful results?

It turned out the study was not as comprehensive as the 149 factors made it appear to be, and was rudimentary to boot.  Included in that 149 factor set were standard blood tests, demographic results, psychological testing, etc.

Wyller testing ME/CFS

Wyller’s testing regimen made a biological result unlikely.

Wyller used a Fatigue Scale – the Chalder Fatigue Scale – believed be problematic in ME/CFS.  His immune tests mostly consisted of immune cell counts which have historically not been particularly effective.  Natural killer cell cytotoxicity – which has consistently been found to be low in ME/CFS – was not done.

The one stressor used – during the autonomic nervous system testing (deep breathing while supine and during 3 minutes of standing) – was too mild (at least a 10 minute tilt table test is needed to diagnose POTS).

While changes in heart rate and blood pressure have been found in ME/CFS, heart rate variability is a more discerning factor and has been more commonly assessed and found altered in ME/CFS – but was not used in Wyller’s study. The cortisol blood test Wyller used has not been found effective in ME/CFS. (Blood cortisol awakening response and morning saliva cortisol tests (not done) have been more effective).

All in all, the study – with its lack of a significant stressor, its limited testing protocol and the use of measures which have not proved useful in ME/CFS – appears to have been almost doomed to failure.  One wonders why Wyller expected to find anything at all, and the results probably could have been predicted.

They also, not surprisingly, opened the door wide open to a biopsychosocial interpretation of ME/CFS that Wyller walked right through.  Wyller reported that,

“Taken together, the results seem to support a biopsychosocial rather than a biomedical perspective on the development of chronic fatigue and CFS.”

Lenny Jason’s Chicago Studies

The next Chicago studies, led by Lenny Jason, will examine many more biological factors in its next iteration. Unlike the Dubbo, Giardia, Wyller’s studies and others, Jason’s samples predate the illness onset, giving him the potential to uncover biological risk factors present before a person became ill.

He has blood samples from over 4,000 students, 4-5% of whom contracted infectious mononucleosis, which they are following. Papers should start appearing this spring/summer. As of October 2018, Jason was still in the process of applying for grants to study blood and saliva factors. They hope to study autonomic functioning, cytokine, metabolomic and saliva biological risk factors.

Jason’s preservation of his samples in a deep freeze means they’ll be able to be assessed as we learn more about ME/CFS over time.  They provide the potential for uncovering perhaps the greatest mystery of all in ME/CFS – what was going on before ME/CFS actually hit that put one at risk for it?

Conclusion

Time will tell if the The Collaborative on Fatigue Following Infection (COFFI) will help, hurt or do anything at all. If the embarrassingly rudimentary website with its weird ads is any indication, the group may not amount to much.

Wyller’s efforts indicate that rudimentary, poorly targeted efforts can do more harm than good if the authors decide to default to a historical norm: if you can’t find something biological, a biopsychosocial explanation must apply.  His results and other biopsychosocial study results are so bizarre, though, that one wonders if anyone will take them seriously.

trigger - post-infectious fatigue

The post-infectious studies have the possibility of catching the disease in the act.

The biological efforts are another story. These cohorts offer the enticing possibility of catching the disease in the act as it first manifests itself. The first post-infectious fatigue studies – the Dubbo studies – are still some of the best, and outlined some findings that have continued to stand: illness severity is a major risk factor and the bugs that triggered the illness in the first place don’t appear to play a role in prolonging it. The early cytokine and genetic results fit that picture: they suggest a stronger than usual early immune response may set the stage for ME/CFS.

Incorporating more sophisticated tests, the Chicago infectious immune studies add the possibility of long-term autonomic nervous system problems, further suggest immune issues play a role and, intriguingly, provide the first signs of impaired energy production during exercise.

Jason, if he can get the money to test his samples, has the opportunity, with his metabolomic, autonomic nervous system and immune testing, to provide more insights into how this illness got started in the first place and why it remains. Plus, his frozen samples provide the opportunity for future researchers to dig even deeper into these questions. They should prove invaluable.