All posts by Cort Johnson

Simmaron Celebrates Ten years of Innovative ME/CFS Research

March 4, 2020

“We envision a world where ME/CFS is treatable and well-understood. To get there, we are scientifically redefining ME/CFS.” The Simmaron Research Foundation

Dr. PetersonIt’s been ten years since the Simmaron Research Foundation for ME/CFS opened its doors. Dr. Daniel Peterson, one of its founders, was restless. Ever since people with a strange, debilitating illness began knocking on his door in the Incline Village outbreak in the mid-1980’s, he’d been focused on ME/CFS. Since then he’d been patiently collecting data and samples – including precious spinal fluid samples – and biding his time until the researchers were ready – and now he thought they were.

With the formation of the Simmaron Research Foundation, Peterson was given the opportunity to put his experience and samples to the test. It turned out that the ME/CFS research community was very interested in what he had to offer.

Research

A Special Partnership

Since its founding, the Simmaron Research Foundation has enjoyed a special relationship with Dr. Mady Hornig and internationally renowned virologist Dr. Ian Lipkin at the Colombia Center for Infection and Immunity. Dr. Lipkin’s interest in chronic fatigue syndrome (ME/CFS) – which began with Dr. Peterson – dates back to 1984. Dr. Lipkin talked about that and his search for more resources in a 2014 video.

 

Simmaron’s Signature Research Effort:

The Cerebral Spinal Fluid Studies

Simmaron’s signature research effort over the past ten years has involved the most intense and potentially difference-making exploration of the spinal fluid yet done in ME/CFS. Bathing the brain, the cerebral spinal fluid provides a unique access to an organ many believe plays a central role in ME/CFS.

Dr. Peterson’s dogged accumulation of cerebral spinal fluid samples over the years paid off in two unique studies. With recent studies providing more evidence of neuroinflammation in ME/CFS, Simmaron’s early decision to commit a substantial amount of resources to spinal fluid investigations is looking prescient indeed.

A gateway to the brain - the cerebral spinal fluid

Simmaron’s signature research efforts have focused on the cerebral spinal fluid – the gateway to the brain.

The first study published in 2017 assessed more cytokines, used more sophisticated statistical analyses (logistic regression/network analysis) and was larger (n=91) than past ME/CFS spinal fluid studies.

The studies started with a collection of samples from many of Dr. Peterson’s sickest patients, which Dr. Hornig called “unparalleled” in their breadth and rigor.

Simmaron sent off two sets of spinal fluid samples – one to Mady Hornig and Ian Lipkin at the Center for Infection and Immunity (CII) for a pathogen and cytokine study and another smaller set to Griffith University researchers in Australia to assess for immune abnormalities.

The CII added a set of multiple sclerosis patients to the mix to produce one of the most interesting studies in years. Few studies had compared MS and ME/CFS patients, and none had assessed the crucial immune factors present in the spinal fluid.

The cytokine levels in both the ME/CFS and the MS patients differed widely from those of the healthy controls. Interestingly, both ME/CFS and MS patients demonstrated reduced cytokine levels – a fascinating finding given the similar finding in the blood for longer duration ME/CFS patients. That finding prompted Dr. Hornig to speculate that, “I think what we’re seeing is an immune system exhaustion over time.”

Despite both diseases demonstrating the same general trend towards immune exhaustion, they differed markedly in the cytokines affected. The cytokines highlighted in ME/CFS suggested an allergic type of reaction – similar to that found in central nervous system infections – was present.  Cognitive decline and aging – two themes in ME/CFS research – as well as reduced neuron production were also highlighted.

The fact that the alterations in the immune factors in ME/CFS were almost as extreme as those found in multiple sclerosis – a disorder characterized by severe central nervous system dysfunction –  suggested that a significant pathological process was indeed occurring in the central nervous systems of ME/CFS patients.

A Hunch Pays Off – The Peterson Subset

“Dr. Peterson’s clinical acumen, his long-term follow up of this patient population and his attentiveness to the full range of complex, serious medical disorders that might develop. The classical group had been followed for similar lengths of time but had not developed these more severe, serious comorbidities.” Mady Hornig

Next, Simmaron and the CII turned to an unusual subset of patients. Dr. Peterson has long asserted that a classical (infectious onset) subset of patients is present in ME/CFS, and is different from what he called a “complex atypical” subset of patients.

Dr. Peterson’s believed his typical “classical” ME/CFS patients came down with a flu-like illness from which they never recovered. His atypical patients, on the other hand, tended to be sicker, have more cognitive problems, have more severe comorbid diseases (autoimmune diseases, cancer), tended to have unusually severe neurological symptoms (such as seizures), and had experienced things like blood transfusions, exposure to infectious agents during international travel, etc.

Many of these illnesses appeared long after the ME/CFS diagnosis. In fact, at the time of diagnosis Peterson reported that the atypical patients looked like a typical ME/CFS patient but felt that some other underlying central nervous system process was underway.

Peterson subset

Dr. Peterson’s intuition that the atypical patients were fundamentally different saved the spinal fluid study – and pointed to a new subset.

Dr. Peterson was so sure, in fact, that an atypical subset of ME/CFS was present – and probably bollixing up study results – that he requested that the group be assessed apart from the other patients in the first Simmaron/CII spinal fluid study. Peterson’s intuition turned out to be correct: the atypical group affected the results so thoroughly that it had to be removed from the first study.

The next study compared the atypical and typical patients. Using Peterson’s spinal fluid samples, The Center for Infection and Immunity (CII) at Columbia found that the “Peterson Subset” displayed a markedly different pattern of immune results: something quite different was going on in their central nervous systems.

Given how sick the atypical patients were, one might have expected their immune factors to be even more reduced, but instead they were increased. In stark contrast to the classical patients, the atypical patients had higher levels of virtually all the immune factors assessed.

Their immune presentation over time differed as well. Almost half their immune factors were lower early in the illness but as the illness proceeded, in contrast to the typical patients, the atypical groups’ immune systems actually revved up again.

Since the higher levels of cytokines in the atypical group would have negated the lower levels of cytokines in the “classical” patients, Peterson’s request that the atypical patients be set aside saved the biggest CSF study in ME/CFS history from a null result. Given the size and expense of the study, that negative result would have dampened interest in the immune aspects of the CSF in ME/CFS for years.

The study demonstrated how critical it is for savvy ME/CFS experts to work hand in hand with research teams to explore ME/CFS – and put the research field on the alert for the apparently very biologically different atypical patients.

The Gut

Since its inception, Simmaron has collaborated with the Columbia Center for Infection and Immunity on several gut studies, including, in 2017, the first study to characterize ME/CFS patients gut flora all the way down to the species level. Prior to this study, ME/CFS gut studies had identified genera, each of which contain many different species, some with very different characteristics. This time, Ian Lipkin used a new approach called metagenomic sequencing to get at the actual players in the gut – the bacterial species.

Simmaron collaborated with the Columbia Center for Infection and Immunity to produce the first study to describe the bacterial species present in ME/CFS patient’s guts.

For the first time, the gut flora of ME/CFS patients with and without irritable bowel syndrome (IBS) was assessed, as well.

Such dramatic differences in bacterial species showed up between the two groups that the researchers were able to distinguish the two simply by comparing their gut flora.

In 2018, Dr. Peterson participated in another innovative CII gut study. Melding together gut flora and metabolomic findings for the first time, Nagy-Syzkal and Lipkin found that ME/CFS and ME/CFS-IBS patients again displayed significantly different gut flora as well as metabolomic signatures.

While problems with fatty acid metabolism were present in both groups, the study found that ME/CFS patients with IBS had additional problems with ATP production and the urea cycle. Plus, the findings suggested high loads of bacterial toxins could be triggering IBS, and pathogens in the gut could be triggering ME/CFS in both groups. On the treatment end, the study findings suggested SMAse blockers might be helpful if the findings are validated.

For all the focus on metabolomics in ME/CFS, a gut microbiome analysis was better able to distinguish ME/CFS patients from healthy controls than a metabolomic analysis. That surprising finding suggested the gut may play a bigger role than we’ve thought in this disease.

Natural Killer (NK) Cells

Dr. Peterson was the co-author of the first NK study, over thirty years ago, to find deficient NK cell functioning in chronic fatigue syndrome (ME/CFS). Following a year-long collaboration between Dr. Peterson and Griffith University in Australia, Griffith found reduced natural killer cell functioning at all time points – indicating that NK problems in ME/CFS are consistent and pervasive.

Peterson’s next Griffith University collaboration found that small bits of mutated RNAs called miRNAs may be contributing to the problems with cytotoxic NK and T-cells in ME/CFS.

Immunology Workshop

In 2014, Simmaron hosted the first ever Immunology Workshop at the IACFS/ME International Conference:

Validating Treatment Successes

Making more effective treatments available for ME/CFS patients has been a goal of Dr. Peterson’s for years. Dr. Peterson’s focus on and his creative approach to infectious onset patients, in particular, has resulted in using and documenting treatments that other doctors might not try.

Dr. Peterson has reported that almost 30% of his patients test positive for active HHV-6 or human cytomegalovirus (HCMV) (via PCR, rapid culture, antigenemia), and a whopping 50% test positive for active Epstein-Barr virus (EBNA) infection.

Simmaron’s core work includes efforts to analyze the effects of little used immune treatments such as Cidofovir (Vistide), Ampligen and IVIG on ME/CFS with a goal of publishing treatment data.

Vistide

In 2013, Dr. Peterson reported on the results of the first retrospective analysis of Vistide’s effectiveness in ME/CFS. Few ME/CFS experts use Vistide but Peterson found that 70% of 65 patients treated from 2005-2012 for HHV6 and/or HCMV infection were either full (able to return to work) or partial (significant increase in functionality) responders; a very high rate of success in an illness characterized by a poor response to treatments.

Only 30% of Vistide recipients did not have a significantly positive response to the drug, and no serious side effects were seen; ironically the minor side effects seen were attributed to a drug, Probocenid, that’s used to ensure that Vistide is absorbed into patients’ systems effectively.

See Report From Paris: Peterson Reports Antiviral (Vistide) Effective in Treating Herpesvirus Infected Chronic Fatigue Syndrome (ME/CFS) Patients for more.

Ampligen 

In 2018, Simmaron and Dr. Peterson reached out to Maureen Hanson and the CDC to help with a project to assess the effectiveness of Ampligen. To this day, Ampligen still remains the only drug the FDA has assessed for ME/CFS. With no Ampligen trials forthcoming Peterson searched for ways to provide a boost for a drug he knows from long experience that can work very well.

Simmaron’s collaboration with Maureen Hanson and the CDC seeks to show why Ampligen is effective in ME/CFS

The novel project took advantage of a year-long lapse in Ampligen availability to assess changes in immune and other factors and symptoms at three time points: (1) while Dr. Peterson’s patients were on Ampligen; (2) when they were off Ampligen; and (3) when they went back on Ampligen.

The extensive testing included NK cell function, cytokine expression, multiple symptom surveys, an exercise tolerance test and Cornell-designed research protocols.  Besides demonstrating how Ampligen works, the study could begin to uncover which subsets of patients it works in.

Gunnar Gottschalk presented preliminary results from “The Workshop for Young Investigators” at the NIH’s ME/CFS Conference in 2019. He reported finding “significant and sustained clinical reduction(s) in both the physical and neurological symptoms following Rintatolimod (Ampligen®)”, including improvements in physical functioning, pain and energy after 6 months of treatment.

An analysis of the biological data is underway.

Next Up For Simmaron

Simmaron’s highest priority is publishing data on ME/CFS subsets and effective treatments – two factors which experience has shown are inextricably linked to one another. Simmaron believes the hidden subsets in ME/CFS have the potential to cloud or nullify the results of biomarker and research efforts as well as treatment trials. On the flip side, elucidating those subsets could produce breakthrough results. To this end, Simmaron’s work is strategically focused on helping the field break out of that conundrum.

Expanded Treatment / Subset Effort

Simmaron

The Simmaron Research Foundation is committed to scientifically redefining how ME/CFS is understood and treated.

Simmaron recently began fundraising for an expanded effort to analyze data from Dr. Peterson’s patients who’ve responded to treatments like Ampligen®, IVIG and cidofovir, as well as amino acid infusions, saline, etc. The goal of these studies is to biologically identify which patients respond to which treatments, and build a scientific roadmap for getting a first medication approved by the FDA for ME/CFS.

Maureen Hanson, PhD of Cornell, is leading the scientific arm of the study, the U.S. Centers for Disease Control is doing statistical analysis; and Dr. Peterson will provide the patients and the treatments.

Simmaron believes the rigorous data analysis being used in these efforts can provide a building block for designing rigorous placebo-controlled trials that have a stronger chance of approval, and ultimately attract pharmaceutical companies to the disease.

Spinal Fluid Study – Round Three

The second phase of the Simmaron/Columbia spinal fluid study now in progress expands the prior studies, and breaks new ground by including a metabolomics analysis. Metabolomics – the study of metabolic by-products – has suggested that a hypometabolic state akin to hibernation may be present in ME/CFS.  This study should shed light on both the metabolic and immune underpinnings of the neuroinflammation believed present in ME/CFS.

Lipkin Brings Disease Busting Technology to ME/CFS

Our biggest weapon in the battle against chronic fatigue syndrome (ME/CFS) has to be the almost dizzying emergence of new technologies being developed. ME/CFS may not have much money, but somehow it’s attracted several pioneers in the medical technology field.

Dr. Ian Lipkin specializes in creating new technologies, one of which he will soon bring to bear on ME/CFS

Ian Lipkin (Columbia), Ron Davis (Stanford), Gordon Broderick (Rochester), and Travis Craddock (Nova Southeastern) aren’t just using the latest technologies – they’re actually creating them. Lipkin, the Director of the Center for Infection and Immunity at Columbia University, and a longtime Simmaron Research Foundation collaborator, is internationally known for his ability to create new molecular diagnostic techniques.

Lipkin developed MassTag-PCR, the GreeneChip system, and was the first to use next generation sequencing technology to identify pathogens. The 1,500 or so pathogens Lipkin identified include the West Nile Virus, numerous tick-borne agents, Lujo virus, MERS-CoV, and Tilapia Lake Virus to name a few. He also played a critical role in battling the SARS epidemic in China.

Lipkin, who has worked with Dr. Dan Peterson for many years, has a long collaborative research history with ME/CFS. Since September 2017, Lipkin has been the Director for the Center for Solutions for ME/CFS (CfS for ME/CFS) at Columbia University funded by the NIH.

Mystery Disease Strikes Children

Lipkin made news recently with his discovery of the apparent cause of a puzzling and devastating disease mostly affecting children called acute flaccid myelitis (AFM). The way the disease develops bears some interesting similarities with ME/CFS.

Several striking bits of evidence suggest a pathogen might be involved. The bug is not new – it first showed up in 1962 – and usually causes nothing more than a respiratory infection  – but in rare cases (600 cases in the U.S. since 2014) it can be devastating.

A spike in AFM incidence in the U.S. in 2014 suggested a virus might have become more prominent.  The fact that most infections appear during late summer and fall as pathogens start to sweep the U.S., plus a CDC report which indicated that the disease almost always followed a respiratory infection, turned a big spotlight on pathogens.

Lastly, symptom onset was abrupt and the disease produced polio-like symptoms such as difficulty moving the eyes, drooping eyelids, facial droop, facial weakness, difficulty swallowing, slurred speech, sudden arm or leg weakness (paralysis). The difficulty breathing that caused some children to be placed on ventilators brought back memories of the iron lung which kept people with polio alive in the early 20th century.

With that the hunt was on for an enterovirus – the cause of polio and a sometimes conjectured cause of ME/CFS. Although attempts to snag the intruder in the cerebral spinal fluid proved fruitless, it wasn’t for lack of trying. The CDC created a task force (which included Avindra Nath, the lead investigator of the NIH intramural study on ME/CFS) and embarked on a cerebral spinal fluid (CSF) study that included over 500 people.

Lipkin Tries New Tack

Lipkin proposed a low viral load, a hit and run virus, and technical issues might be bollixing up the PCR search in AFM, and turned to a much more powerful new technology developed by his team called VirCapSeq-VERT, as well as the use of peptide arrays that looked for immunological responses to pathogens. (VirCapSeq-VERT with its ability to detect novel and mutated viruses is like PCR on steroids.)

The peptide arrays proved the trick. Lipkin found antibodies to EV peptides present in almost 80% of the study participants’ CSF, and zeroed in on a specific enterovirus called EV-D68.  Since then a separate study has confirmed his finding. Now some researchers are calling acute flaccid myelitis “the new polio“.

Lipkin on Acute Flaccid Myelitis

ME/CFS Next

Lipkin will begin testing people with ME/CFS shortly

Lipkin will soon begin testing ME/CFS samples

The question now is whether Lipkin can do the same thing for ME/CFS. A VirScan analysis funded by Solve ME failed to produce results; however, that method may not have had the specificity needed to find the footprints of an infectious agent. Lipkin and his colleague Dr. Nischay Mishra are using the same Serochip method they used to solve AFM, to begin an intensive search for an immunological response to a pathogen (viruses, bacteria, endogenous retroviruses, fungi) in ME/CFS.

The Serochip will scan through up to 6 million peptides (small amino acid chains) in an attempt to uncover a hidden pathogen that has been, or still is, tweaking ME/CFS patients’ immune systems. The work could also uncover an autoimmune reaction.

ME/CFS with its multiple subsets is likely far more complex than AFM, but if Lipkin can find a distinct immune signature or more likely distinct immune signatures in ME/CFS, he might be able to break another mysterious, pathogen triggered disease wide open.

Lipkin and his team will begin testing the blood or spinal fluid of ME/CFS patients in early 2020.

Click on the stories below for a look back at Simmaron’s collaborative work with Dr. Lipkin.

Ian Lipkin & Simmaron to Collaborate in New NIH ME/CFS Research Center

Peterson’s Atypical Subset Opens New View of ME/CFS in Columbia/Simmaron Publication

Simmaron’s Spinal Fluid Study Finds Dramatic Differences in Chronic Fatigue Syndrome

Finally Found – A Natural Killer Cell Enhancer for ME/CFS?

For several years now, researchers at the National Centre for Neuroimmunology and Emerging Diseases (NCNED) at Griffith University in Australia have been leading the research on natural killer (NK) cells in chronic fatigue syndrome (ME/CFS). In fact, they recently published an overview on NK cells and ME/CFS.

natural killer cell failure ME/CFS

The natural killer cells in ME/CFS are pretty much a failure at killing infected cells.

NK cells play a critical role in the innate immune response which kicks in first to fight off an infection.  NK cells do just what their name implies: after alerting the immune system that trouble is ahead, they jump in and kill as many infected and damaged (cancer) cells as possible. The goal? To keep a pathogen in check long enough for big guns of the adaptive immune system (T and B cells) to rev up and ultimately destroy the invader.

For some time now, the Griffith group has focused on an unusual subject for ME/CFS –  ion channels – the very, very small channels in our neurons and cells – which play a big, big role in nerve and cell activation. Ion channels are getting a lot of interest in pain research but except for the Griffith team – not so much in ME/CFS.

The problem with NK cells in ME/CFS is that they’re just not killing very well. When given the chance to wipe out some infected cells, they pretty much poop out – not good news for anyone wanting to quickly knock down infections or remove cancerous cells.

NK cells, like many cells, require intracellular calcium to function properly, the levels of which are regulated, at least in part, by the ion channels the Griffith group is studying. These TRPM ion  channels are found in a wide variety of cells and tissues, and play a particularly important role in  sensory processing – a big concern in ME/CFS.

The ion channel that the Griffith group has been particularly interested in – TRPM member 3(TRPM3) – appears to be a jack of all trades. The fact that it can be activated by everything from temperature, natural chemicals, and toxins to synthetic compounds suggests it plays a fundamental role in the body, and, indeed, TRPM3 dysfunction has been implicated in inflammatory and neuropathic pain disorders.

Ion Channels and ME/CFS

The Griffith group’s findings in ME/CFS stretch back almost four years. In 2016, they showed that both TRPM3 and intracellular concentrations of calcium were reduced in the NK cells of ME/CFS patients. These findings suggested that in ME/CFS, the signal to kill  the pathogens wasn’t getting through to the NK cells.

That same year, Griffith introduced a potential explanation: the genes that governed TRP ion channel functioning – in particular, TRPM3 ion channel functioning – were loaded with mutations in ME/CFS. That same year, the group reported they’d found similar mutations in the B cells of ME/CFS patients.

ion channel issues

The ion channel / Ca mobilization issues in ME/CFS (From Impaired calcium mobilization in natural killer cells paper_

2017 brought another study validating the TRPM3 channel reductions. Further testing indicated something had gone wrong with the TRPM3 receptors themselves. When stimulation tests found a reduction in Ca2+ mobilization was occurring, the researchers proposed something startling: that TRPM3 channels across the body could be malfunctioning.

“As TRPM3 receptors are expressed throughout the human body, the current findings suggest that impaired TRPM3 function may play a significant role in the multisystemic pathomechanism of CFS/ME.”

Given how ubiquitous TRPM ion channels are, the loss of them body-wide could be responsible for many of the multitudinous symptoms associated with ME/CFS.

2018 and 2019 brought further validation of their previous findings (in small studies).  Just this month, the group published evidence that a related ion channel, TRPM2 – perhaps in a compensatory response – is over-expressed on ME/CFS patients’ NK cells. Despite its increased levels, it too was not functioning well.

Then in October of this year came a potential fix for the NK cell problem in ME/CFS.

Front. Immunol., 31 October 2019 Naltrexone Restores Impaired Transient Receptor Potential Melastatin 3 Ion Channel Function in Natural Killer Cells From Myalgic Encephalomyelitis/Chronic Fatigue Syndrome Patients, Helene Cabanas1,2,3*Katsuhiko Muraki3,4,  Donald Staines1,2,3 and  Sonya Marshall-Gradisnik1,2, https://doi.org/10.3389/fimmu.2019.02545

Naltrexone hydrochloride (NTX) is best known in its low dose form in ME/CFS. It was referred to in this paper, though, simply as naltrexone. NTX in its normal dose functions as an opioid antagonist which reverses the effects of opioids. While it’s doing that, it also happens to activate the same TRPM3 channels that have been found inhibited in ME/CFS.

The Australian researchers used something called a whole cell patch clamp technique to assess the functioning of NK cells from people with ME/CFS. This technique, which was developed in the 1970’s/80’s, enabled researchers to assess the functioning of single ion channels on cells for the first time. (It also won its creators the Nobel Prize.)

The study again found that low levels of TPRM3 channels were present in ME/CFS.  It showed that stimulating the NK cells from healthy controls worked – the NK cells sprang into action. The NK cells from the ME/CFS patients responded to the stimulation by remain dead as a door nail. That stimulation test suggested that whatever TPRM3 channels were present simply weren’t working.

ME/CFS patients, then, appeared to have two problems: they were losing TRPM3 ion channels and those that were still present were not working well.

Incubating the healthy controls’ NK cells in naltrexone had no effect on them, but the ME/CFS patients’ NK cells responded dramatically: they now appeared to be acting normally.

Besides presenting a possible treatment for the NK dysfunction in ME/CFS, the finding suggested the Griffith researchers’ original hypothesis could be correct: the mysterious NK cell dysfunction problem could derive from problems with the TPRM3 ions.

Sonya Marshall-Gradisnuk was enthusiastic about her team’s results

This was a laboratory study – a proof of concept study. It’s a long way from testing naltrexone in humans but it did hold out the potential of a treatment for the low NK functioning in ME/CFS.

Given that NK cells ferret out infected and cancerous cells and remove them, getting the NK cells functioning properly again in ME/CFS would be a big step forward.

The leader of the group, Sonya Marshall-Gradisnik, was clearly enthusiastic:

“This world-first discovery suggests new potential pharmaco-therapeutic interventions in ME/CFS.”  Professor Sonya Marshall-Gradisnik

Opioid Drugs and Immunosuppression

The study also raised the question of what effects opioid drugs could be having on the immune systems of people with ME/CFS. No studies have attempted to assess that issue, but this study and others suggests it could be negative.

Opioid drugs have been found to impair the functioning of macrophages, natural killer cells and T‐cells and weaken the gut barrier.  A 2013 review asserted that, given the prevalence of opioid use, “opioid-mediated immune suppression presents a serious concern in our society today”.

The effects of opioids are complex, however. Immune cells also secrete endogenous opioid peptides which relieve inflammatory and neuropathic pain.

Conclusion

 

breakthrough

A breakthrough for ME/CFS? Time will tell.

The studies have generally been small, but the results have been consistently positive. They suggest that poorly functioning TRPM3 and perhaps related ion channels could be causing the reduced NK cell cytotoxicity commonly found in ME/CFS. This study found that the opioid antagonist Naltrexone was able to reverse the TRPM3 and calcium mobilization problems in ME/CFS patients’ NK cells.

Reversing the poor NK cell cytotoxicity functioning to normal would be a major step forward. Further studies will be needed, however, to determine if the results seen in the laboratory apply to people with ME/CFS – which is often a perilous step. I couldn’t find any clue as to what the effective dose would be or whether the low dose form of naltrexone might help.

It bears mentioning that the Griffith group has evidence that another ion channel may not be working properly in ME/CFS, that these channels are widespread throughout the body, and a systemic dysfunction with them, if present, could cause many problems.

 

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Solid Ground at Last? Cytokines Make Good in Major ME/CFS Review

The immune system in chronic fatigue syndrome (ME/CFS) has been kind of like a mirage in the desert. Given the way the disease starts and its symptom presentation – so close to the “sickness behavior” produced during an infection – it seems that the immune system must be a major player in this illness.

desert lake

Powerful immune factors called cytokines seem like they must be involved in ME/CFS but inconsistent results have caused them, like a mirage in the desert, to slip away again and again (Image by TravelCoffeeBook from Pixabay )

Like a mirage in the desert, though, the powerful drivers of the immune system – the cytokines – seem to slip through our grasp again and again.  Interesting findings pop only to be dashed by another study.

Thirty plus years of study have left us – according to several immune reviews – with precious little solid ground. A recent review, however, suggested that larger studies were finally producing more consistent results.

Now we have the largest “study” of all – a meta-review of past cytokine (inflammatory protein) studies – that’s providing us a solid foundation, and from the unlikeliest of places, Kings College in the U.K., which has been better known as a bastion of cognitive behavioral therapy.

The senior author of the paper, the rather prolific Anthony Cleare, has focused for years on the HPA axis in ME/CFS. He and the lead author, Rebecca Strawbridge, have shared an interest in the role inflammation plays in HPA axis issues and depression. Strawbridge’s recent paper on the effectiveness of anti-inflammatories in depression clearly underscored how often inflammation instead of psychology is driving depression.

Their new paper’s rather emphatic title “Inflammatory proteins are altered in chronic fatigue syndrome-A systematic review and meta-analysis” seemed to give notice that things had changed. ME/CFS is, at least in part, an inflammatory disease after all.

The review was broad: any diagnostic criteria was allowed and the main exclusionary criteria was that no stimulation of any kind was involved; i.e. this was an assessment of the immune system at rest. The 42 studies involved highlight just how hard researchers in this small field have searched for an immune cause of ME/CFS.

The authors of the present paper pointed out why the immune system has been such a draw for this field. “Phenomenologically” they noted, “ME/CFS is often described as a ‘flu-like illness’ and the diagnostic criteria to some extent resemble the symptoms of sickness behaviour.” (Sickness behavior describes the symptoms produced by the brain during infection (fatigue, pain, cognitive problems, etc.) that serve to isolate an individual from the community – and thus help stop the spread of a pathogen).

The Review

The vast majority of studies used either the Fukuda or the 1994 criteria created by the CDC. Both criteria have been mostly discarded in favor of more recent criteria but it should be noted that most ME/CFS studies – including many with positive outcomes – used one or other of these definitions. (Only 8 of the 42 studies used the Canadian or International criteria – which may have issues of their own.)

Despite the broad criteria (Oxford definition, CDC definitions included) used in most of the studies, this meta-review actually found evidence for an inflammatory state in ME/CFS. The authors hypothesized that pro-inflammatory cytokines and acute phase protein levels would be significantly higher in people with ME/CFS than controls, and low and behold, they were.

cytokines

Cytokines and other inflammatory proteins turn on (or off) the immune system. High levels of pro-inflammatory cytokines produce inflammation.

Approximately 22 cytokines/immune factors were assessed in 42 studies dating from 1989 to 2016.  The review suggested that about a quarter of the immune factors assessed in ME/CFS were elevated.

Elevations of two cytokines (tumor necrosis factor-a (TNF-a), c-reactive protein (CRP)), both of which have wide ranging effects, suggested that ME/CFS was similar to other  “chronic immune conditions” which have a similar cytokine profile.

Synchronicity

A recent gene expression study highlighted both TNF-a and TGF-B as well.  In fact, that study identified precise pathways associated with TNF-a which might potentially be targeted in ME/CFS. The fact that these cytokines are popping up in independent studies suggests we may finally be honing in on some key cytokines that are producing fatigue, pain and other symptoms in ME/CFS.

New Pathways: A Step Towards Fine-Tuning Treatments for ME/CFS?

Cytokines involved in regulating inflammation ((IL-2, IL-4 and TGFβ) appeared to be particularly affected. Three cytokines (IL-6, IL-1 and IL-12) involved in the early response to infection (perhaps suggesting viral reactivation was present) tended to be increased as well but were less consistently elevated. Interestingly, given the hypothesis that immune exhaustion occurs over time in ME/CFS, no trends in reduced cytokine levels were found.

Capturing Smoke in a Bottle

The authors noted that some similar (but different) findings have been found in fibromyalgia and depression, and that given the widespread co-occurrence of all three disorders teasing what is caused by what is tricky. Noting that fatigue is found in both ME/CFS and depression, and that inflammation can produce “disabling fatigue”, the authors suggested  future studies more clearly delineate the extent of depression present. Activity levels and medication use – both of which can affect the HPA axis or immune system should be characterized. .

The review also noted, as did Van Elzakker’s rather scathing recent review of cytokine studies, that measuring cytokines is a bit like capturing smoke in a bottle. Their levels fluctuate constantly and can be effected by activity levels, diet, medication use, weight, age, sex and “numerous other factors”.

For instance, it’s clear that activity levels, diet, medication use – all factors which could skew cytokine findings – will probably be different in ME/CFS patients. Therefore, they could by themselves account for the altered levels found. Plus a bunch of other factors (severity and duration of illness, illness triggers, illness history, sample collection, processing, storage) could all tweak cytokine levels.

Given that few ME/CFS studies accounted for most of these factors (and mostly used outdated criteria) it seems remarkable that the review found consistent results at all.

A Plea for A Cytokine Study (To End All Cytokine studies)

Once again, for the umpteenth time it seems, the authors left us with a plea for larger, more rigorously controlled studies. The authors, in fact, recommended what sounded like a cytokine study to end all cytokine studies. That study would subgroup patients, assess all confounding factors and then follow the patients over time (longitudinal study).

drug trial ME-CFS

The authors “fervently” hoped a large, rigorous cytokine study could identify key cytokines that could be targeted with drugs.

A very large study using the best criteria available could tease out definitive immune biomarkers and pave the way for potential treatments. The increasing number of biologic drugs being developed to target specific cytokines make that drug arena a potentially very fruitful one for ME/CFS.

Dr. Klimas is certainly on board. Her Enbrel (plus mifepristone) trials in ME/CFS and GWI indicate she thinks she’s already found a target. Enbrel, interestingly, targets TNF-a – one of the cytokines the review found elevated in ME/CFS.

Breaking their British reserve a bit at the very end of the paper, the authors stated they “fervently” await better studies so that they can conduct a more comprehensive meta-analysis- and better understand the role that inflammatory proteins play in ME/CFS.

One wonders if we could be just one or two very big, rigorous and comprehensive cytokine studies away from identifying an FDA-approved drug that could help many. This review will surely provide support for studies like that.

New Pathways: A Step Towards Fine-Tuning Treatments for ME/CFS?

Most chronic fatigue syndrome (ME/CFS) studies focus on females, but for once we have a study contrasting females and males. It makes sense that this group – hailing from Dr. Klimas’s Institute for Neuroimmune Studies, the University of Miami, the Veterans Center in Miami, the University of Rochester and the University of Alberta – would study both genders. Their modeling studies have made it clear that gender matters.

make-female

Gender matters…(How could it not?)

This small but intense study compared the gene expression of 23 females and 10 males with ME/CFS and 21 healthy controls. The U.S. and Canadian researchers then isolated the most impactful genes and compared them, gender to gender and ME/CFS patients to healthy controls.

They then used a variety of fatigue measures to identify which genes were most associated with fatigue. With these fatiguing genes in hand, they then cross-referenced their results with a genetic-drug database to see which drugs might potentially be useful in ME/CFS.

Results

Treatment Avenues in Myalgic Encephalomyelitis/Chronic Fatigue Syndrome: A Split-gender Pharmacogenomic Study of Gene-expression Modules Mary G. Jeffrey, M.A.1,2; Lubov Nathanson, Ph.D.1,3; Kristina Aenlle, Ph.D.1,3,4; Zachary M. Barnes, B.Sc.1,4,5,6; Mirza Baig, M.P.H.1; Gordon Broderick, Ph.D.1,2,3,7,8; Nancy G. Klimas, M.D.1,2,3; Mary Ann Fletcher, Ph.D.1,3,4; and Travis J.A. Craddock, Ph.D.1,2,3,9. Clinical Therapeutics/Volume 41, Number 5, 2019

Size Matters –  for Men and for Women

The first thing that stood out was that sample size clearly matters.  While the men – probably due to the small sample size (n=10) – flunked out when it came to looking for differences in gene expression, the women (n=23) excelled.

The active pathways identified in the men (growth factors, immune factors, cardiac/blood factors, transcription factors, and mitochondrial factors) made sense but were identified as having only a small to medium effect on their illness.  On the other hand, some of the pathways identified in the women (mostly the same as the men) appeared to have large to huge effects on their illness.

Only one measly gene was significantly differently expressed in the men compared to healthy controls, but 189 were significantly differently expressed in the ME/CFS women.  As far as gender goes many of the pathways were similar in both genders,  but several gene modules were only highlighted in the women (TGF-b β Signaling signaling pathways, TNF-αa, and T-cell Receptor pathways).

That suggests that the illness has similar underpinnings for both genders. Whether you are male or female, ME/CFS, they asserted, is a “stress mediated illness with underlying endocrine, immune, and mitochondrial imbalances accompanied by autonomic and physical dysfunction”; i.e. it’s definitely a complex disease. Some of those imbalances, though, are probably different in men and women.

Given the preponderance of women with this disease (and fibromyalgia) one has to ask how gender could NOT be an issue. These groups are, thankfully, looking into gender issues further.  In fact, they may be the only research group that’s explicitly looking at the similarities and differences between men and women with ME/CFS.

Note the word “imbalance” in the group’s description of the disease (“a stress mediated illness with underlying endocrine, immune, and mitochondrial imbalances”). ME/CFS is not organ damage; Klimas and Broderick et. al. believe our systems are “simply” out of balance and that’s potentially good news; it’s easier to tweak, reprogram, reset a system than repair physical damage.

Rest Button?

System reset

The big question: which buttons to push to reset ME/CFS? (Image by Gerd Altmann from Pixabay )

They identified one possible reset button – the JAK-STAT pathway. When the stress response gets jacked up (and it may be jacked up all the time in ME/CFS) the JAK-STAT pathway transmits information from cytokines and growth factors to the cell nuclei. If that pathway is not working properly – and there’s some evidence that it is not in ME/CFS – every time the stress response system gets activated, a discombobulated JAK-STAT pathway tells your cells to do the wrong thing.

The Klimas group is not the only one to think the answer lies in signaling errors which cause our systems to overreact.  Jarred Younger believes the glial cells in ME/CFS patients’ brains may be pumping out cytokines at the slightest sign of trouble.  The massive reaction Alan Light found to muscle metabolites during exercise didn’t appear due to high numbers of muscle metabolites. Instead, small amounts of muscle metabolites appeared to be producing massive overreactions in ME/CFS patients’ immune and endocrine systems.

The Fatigue Systems

The gene expression modules the Klimas/Broderick groups found most associated with fatigue were particularly interesting. In a nice piece of synchronicity, the two systems that popped up – the immune system and metabolism – are major research topics in this disease.

In the immune system, two cytokines popped up: TGF-B and TNF-a.

TGF-b is notable for being the only cytokine found to be consistently upregulated in a metanalysis of ME/CFS immune studies. This TGF-B pathway – which is highly associated with “sickness behavior” – was highlighted in both men and women with ME/CFS. Upregulation of this pathway can impair “motor activity” (exercise), affect energy production, produce sleep problems and cognitive issues; i.e. increased levels of it in ME/CFS could be producing “malaise” or fatigue, problems with thinking, poor sleep, etc. that often occurs when we are fighting off an infection (“sickness behavior”).

TNF-a is a major, major cytokine in any immunologist’s book. Increased TNF-a expression in the ME/CFS group was associated with a host of problems including worsened vitality, physical functioning, social functioning, pain levels, fatigue, and sleep disturbances. TNF-a could also be contributing to the “malaise” in ME/CFS via its activation of the excitatory neurotransmitter glutamate in the brain.

TNF-a is an excellent cytokine to show up in ME/CFS for a couple of reasons: it’s known to be dangerous, it’s associated with many serious diseases, it’s getting a lot of research work, and drugs have and are being developed to affect it.

The “metabolism of protein module” was, remarkably, associated with virtually every aspect of fatigue tested (physical functioning, physical limitations, SF-36 total score; general fatigue, physical and mental fatigue, reduced activity). That module, the authors suggested, could reflect an mass of inflammatory metabolites being pumped out in ME/CFS: in other words, it may all goe back to inflammation.

Building the Foundation for Fine-tuned Drug Interventions

Now that they’d identified some possibly key immune issues in ME/CFS, they asked what treatments might help. Dr. Klimas has for several years evinced a strong desire to begin immune based treatments in ME/CFS. This study was clearly intended to help build the evidentiary basis for using immune drugs in ME/CFS.

Cross-referencing the gene expression results from the women with a National Institutes of Health (NIH) funded pharmacogenomics database called PharmGKB yielded several drug possibilities. The PharmGKB database provides clinical guidelines on using a person’s genetic information to determine which drugs might be effective. As far as I know this is the first time this database has been used in ME/CFS research.

In what appeared to be another first, the researchers didn’t simply look for drugs that could affect TNF-a – an immensely powerful cytokine which can affects many different pathways. In a step forward for personalized medicine in ME/CFS, they looked for drugs that could affect the specific pathways (M18, M41) the study indicated TNF-a was disrupting in this disease.

immune pathways

The goal: finding the precise immune pathways affected in this disease – and a treatment to match them. (Image by Siggy Nowak from Pixabay )

A search for the M41 pathway, for instance, found a host of potential drugs (selective immunosuppressants, sulfonamides, aminoquinolines, and TNF-a Inhibitors) which could potentially tweak that pathway in ME/CFS. No specific FDA approved drugs, on the other hand, are focused on TGF-B, but the authors noted that TGF-B is an area of active research.

It will certainly take time and much bigger studies glean out the specific immune pathways that are disrupted in ME/CFS, and to provide the evidence base that could allow doctors to prescribe drugs for them.

This study suggests, though, that this is not rocket science. We have the technology to help identify the precise pathways disrupted in ME/CFS. We simply need the funding (and the large sample sizes) to do that.

One wonders if, at some point patients will be able to get drugs designed to tweak the specific immune pathways at play in their ME/CFS.

A Complex Disease Demands A Complex Effort

“As such, there exists the potential for symptom subtypes of ME/CFS for which a single overarching treatment strategy may not be effective. Beyond this, the presence of comorbid conditions adds a layer of complexity”  The authors

As the article ended the authors focused on how complex the disease with its multisystem presentation, and many comorbid illnesses, is. ME/CFS, they asserted, is not a “one disease, one-target” disease; it’s probably going to take multiple treatments aiming at a variety of targets to turn this disease around.

Possibly preparing us for some underwhelming results, they stated that their original treatment model for ME/CFS – the etanercept/mifepristone drug combination that was designed to first smack inflammation down, and then reset the endocrine system – needed some tweaking.

“While in our previous studies the profile of ME/CFS in women suggested targeting the Th2 immune cytokines followed by inhibition of the glucocorticoid receptor system, this predicted drug course has not yet been optimized.

The fact that their model is going to get some more tweaking is no surprise at all given the complexity of the systems they’re trying to effect. The surprise would be if the models weren’t being continuously tweaked as new data trickles; i.e. the models should only get better over time.

 

Researchers Closing in on Definitive Lyme Tests As NIH Amps Up Lyme Efforts

It wasn’t until 1983 that Borrelia burgdorfii, a bacteria carried by the black-legged or deer ticks, was identified as the cause of Lyme disease. That didn’t mean a good diagnostic test has been available – far from it.

None of the currently available tests (PCR, antibodies) are anything near definitive. PCR tests often fail when they simply miss the low numbers of bacteria present. The most commonly used tests, antibody tests, on the other hand, don’t begin to be accurate until a month or more into the disease.

That’s not a good scenario for a person bitten by a tick who needs a quick regimen of antibiotics to ward off the potential joint, connective tissue, heart and nervous system complications that can occur, 20-30% of whom never get the infamous Lyme rash. Public health authorities estimate that as many 300,000 people are exposed to Lyme disease every year – but only 30,000 cases are reported.

Lyme disease

Lyme disease has been a scourge for decades, but doctors still use tests developed in the 1990’s.

The current tests are so problematic that health officials in areas with high rates of Lyme disease often simply provide prophylactic doses of antibiotics to anyone exposed to a tick who comes down with a fever, headache, etc.

Plus people who remain ill after treatment, or who are diagnosed using controversial tests, can be given long term courses of antibiotics long term which carry their own risks. The number one thing that’s wanted and needed in the Lyme world is an effective diagnostic test. The good news is that one may be on the horizon.

The current slate of antibody tests were agreed upon back in 1993 at the Dearborn Conference when our understanding of Lyme disease was in its infancy. Twenty three years later, experts experienced in the clinical and laboratory aspects of Lyme and other infectious diseases met at the Cold Spring Harbor to discuss better Lyme diagnostic tests.

That meeting and discussions afterward laid the basis for a 2019 Viewpoint article in the Journal of Clinical Infectious Diseases with the provocative title, “Direct Diagnostic Tests for Lyme Disease“.

Direct Diagnostic Tests for Lyme Disease

Direct Diagnostic Tests for Lyme Disease Steven E Schutzer Barbara A Body Jeff Boyle Bernard M Branson Raymond J Dattwyler Erol Fikrig Noel J Gerald Maria Gomes-SoleckiMartin Kintrup Michel Ledizet … Show more Clinical Infectious Diseases, Volume 68, Issue 6, 15 March 2019, Pages 1052–1057, https://doi.org/10.1093/cid/ciy614

The Viewpoint effort was lead by Stephen Schutzer – an immunologist and sometime ME/CFS researcher – who in 2011 used an analysis of proteins in the cerebral spinal fluid to distinguish post-treatment Lyme disease from chronic fatigue syndrome (ME/CFS).

The authors got right to the point: the serologic tests presently used, they wrote, “cannot distinguish active infection, past infection, or reinfection”. “Reliable direct-detection methods, on the other hand, now appear achievable”.

It should be noted that the scientific advances allowing such statements to be made provide hope not just for Lyme disease patients but for those with other difficult-to-detect infections. Reliable diagnostic tests have recently been developed quickly for a number of newly emerging diseases such as Middle East respiratory syndrome – coronavirus, Zika infection, and even 2 newly recognized tick-borne borrelia infections (Borrelia mayonii, Borrelia miyamotoi).

B. burgdorfii is a different case, however. Three factors in its makeup (low bacterial load, high antigenic diversity and a wacky genome) have made it particularly difficult to capture.

Antigen Capture

Instead of directly looking for the bacteria itself, it’s possible to look for the antigens (proteins) the bacteria sloughs off into the blood, urine, etc. Past antigen capture efforts have been thrown off by the high antigenic variability found in the Lyme bacteria but new developments in mass spectrometry, and antigen enrichment and stabilization are making antigen capture a real possibility for capturing B. burgdorfii. 

A Better PCR

B burgdorfii

Three aspects of B. burgdorfii make it difficult to find.

B. burgdorfii’s second trick for evading capture – low bacterial loads in the blood – have made it difficult to capture by PCR.  Enter high-throughput sequencing techniques that have been developed to scan larger blood samples. Frequently used to detect exotic infections, the authors asserted these techniques can “be applied successfully to Lyme disease diagnostics”.

They know – because they’ve done them. These tests, which are 200 times more sensitive than normal PCR, may just be the tip of the iceberg, though. Adding other measures to their Lyme test kit allowed the authors to increase the sensitivity of their PCR a jaw-dropping 16,000 fold – enabling them to catch many more cases of Lyme disease than had been previously detected.

Instead of the .5 ml of plasma usually taken, the authors took 1.25 ml of whole blood, used a technique to amplify the bacteria present, and then used multiple primers.

Next Generation Sequencing

B. burgdorfii’s third evasive maneuver – its complex and unusual genome consisting of high levels of circular plasmids – has enabled it to evade capture in the past, but the development of a new technique (“long-read sequencing”) has allowed Pacific Bioscience to uncover hallmark sequences of the bug’s genome that can conceivably be targeted in diagnostic tests.

Serology Not Dead Yet

Serological testing, which relies on assessing the immune response to the bug, has a couple of problems, but doctors are familiar with serological testing and it may be cheaper and easier to use than other techniques. Improved serological testing could clearly provide a boon as well.

Just a week ago, a biomedical engineering group from Columbia published a study using a new serological test which purportedly can diagnose a Lyme infection in just 15 minutes. This test which uses “microfluidics” was much more effective than the standard tests at diagnosing early infections. The test needs to be further refined and tested, but the early results were good.

Effective Lyme Test Now Technically Possible

The advances enabled the authors to assert that “the goal of an active-infection diagnostic test is now technically achievable”. Note the word “technically”. We’re not there yet.

Understanding the full breadth of B. burgdorfii’s genetic diversity, creating better genomic databases, optimizing sample collection procedures and other issues need to be resolved for that to happen. That’s all a matter of funding; i.e. the political will to get the Lyme (and other tick-borne illnesses) under control.

New NIH Emphasis on Lyme Disease 

Finally, in a last bit of good news – the NIH will be ploughing more resources into Lyme research over the next five years.

Lyme disease has differed little from ME/CFS, fibromyalgia and others in its neglect at the NIH, and new NIH emphasis on Lyme was the result of years of advocacy work. In some ways, ME/CFS advocacy is on a parallel track – it’s just a few years behind. A Congressional Lyme Disease Caucus,led by two Lyme champions, and that was officially formed in 2013, paved the way.

Lyme strategic plan

Years of advocacy paid off when the NIH published a strategic plan for Lyme. The NIH is now working on a strategic plan for ME/CFS.

The 2016 21st Century Cures Act mandated the establishment of the Tick-Borne Diseases Working Group the NIH. In 2018, that group produced a report outlining recommendations for research which included increasing funding, improving diagnostics and, more importantly, developing a strategic plan.

That plan was recently published, and when it was, Rep. Chris Smith, one of the leaders of the Lyme Caucus, and a long time advocate for more Lyme research, reported advocacy efforts had paid off:

“After lagging for decades, NIH is all in for researching Lyme and other tick-borne diseases to better diagnose and treat those suffering from this horrific disease. This is great news for patients and Lyme-literate doctors who will now have serious, federal partners working aggressively to improve strategies for the detection, treatment, and one day, prevention of Lyme.”

That plan includes a number of intriguing focii, including determining the cause of an ME/CFS-like disease (post-treatment Lyme disease syndrome), better understanding the only known food allergy that can be induced by an insect bite (alpha gal syndrome), and developing rapid and direct detection diagnostic tests as well as vaccines and immune-based treatments.

Lyme isn’t the only neglected disease benefiting from effective advocacy. The money the HEAL project is pumping into efforts at the NIH to fight the opioid epidemic and create better pain drugs resulted from a public outcry. ME/CFS, with its ramp-up of advocacy efforts, and the NIH’s work on a strategic plan, is hopefully following a similar path as Lyme disease.

See- Did a Pivotal Moment for ME/CFS Just Happen?

Smith is not nearly done with Lyme advocacy. His next trick is a bill (TICK Act (HR 3073) that would create a national strategy to prevent and treat Lyme and similar diseases.

Conclusion

Rapidly decreasing technological costs are helping the search for better diagnostic tests. More work needs to be done, though, to validate a test and bring it to market.

The takeaway message from the Direct Diagnosis paper is that we now have the technology needed to develop a reliable, effective test for Lyme disease. Such a test would identify many people who don’t know they have the disease and stop unneeded treatment in those who don’t have it. It should also help us understand what’s going on in those who have been treated and remain ill (post-treatment Lyme Disease).

The missing element has been the political will to comprehensively tackle the disease and provide the necessary research funding.

That appears to be changing as well. Years of advocacy paid off with the recent production of a strategic plan to comprehensively fight Lyme disease. The NIH’s new emphasis should further advance the development of better diagnostic tests and, hopefully create new treatment possibilities. With ME/CFS on a similar path with it’s own strategic plan being developed, it’ll be illuminating to see how much Lyme disease funding shoots up over the next couple of years.

More on Lyme Disease From Simmaron

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

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.