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The Blood Vessel Crunch: A Unifying Hypothesis for ME/CFS

This is another hypothesis paper that gives one hope – and makes one wonder if the authors might have a handle on what’s happening with chronic fatigue syndrome (ME/CFS). The paper proposes that a tantalizingly simple problem – an autoimmune attack on just one receptor – out of hundreds of potential receptors –  could be causing virtually all the symptoms of ME/CFS.

B2AdR

Could an autoimmune process attacking the B2 adrenergic receptor be causing the symptoms of ME/CFS?

Receptors dotting the surface of a cell don’t seem impressive, but they’re actually the key to the activity of our cells. Lock onto a receptor and you make the cell change. Most drugs don’t target cells – they target the receptors on cells.

Could just one messed up receptor, though, produce the symptoms of ME/CFS? If it’s an important enough receptor found in enough places – yes, it can, and the receptor in question in this paper –  the beta-2 adrenergic receptor or B2AdR is indeed a heavy duty receptor.

Found in the blood vessels in the brain, the skeletal muscles and the heart, it is a downstream mediator of the sympathetic nervous system (fight or flight system)  which among other things, controls blood flows.

The evidence for B2AdR dysfunction in ME/CFS is building. It’s not overwhelming – it’s not a done deal, but it’s pointing in a very intriguing direction.

One study from a Simmaron collaborator has found elevated levels of B2AdR autoantibodies (antibodies that attack the receptor) in ME/CFS and another is believed on the way. Small mutations in the genes that produce the receptors have been found as well. Plus, similar mutations have been associated with a kind of mild ME/CFS-like state as well. Finally, Scheibenbogen’s work suggests that ß2AdR autoantibodies stimulate the ß2R signaling, but in a subset of ME/CFS patients their functioning has been blunted.

Simmaron Research collaborated with Carmen Scheibenbogen in a pilot study of B2AdR autoantibodies in ME/CFS by contributing patient samples and funding in 2018.

Unifying Hypothesis?

That was enough evidence for Klaus Wirth MD and Carmen Scheibenbogen MD in Germany to believe they had to get the word out and in doing so built a grand, indeed a “Unifying” hypothesis of ME/CFS.

A Unifying Hypothesis of the Pathophysiology of Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS): Recognitions from the finding of autoantibodies against ß2-adrenergic receptors. Klaus Wirtha, Carmen Scheibenbogen, Autoimmunity Reviews, 2020

Numerous documented problems in ME/CFS including low heart rate variability, chronotropic incompetence (inability of the heart rate to increase appropriately during exercise), something called QTc shortening (shortened ventricular repolarization)

The ß2AdR’s in the blood vessels play an important role in opening or dilating the blood vessels  enough during exercise to accommodate up to 20-fold increases in blood flows muscles will see.  In order to do that the blood vessels release a wide variety of vasodilators such as adenosine, ATP, prostaglandins, (PGEs), prostacylin (PCI), bradykinin (BK) and protons.

scheibenbogen

Carmen Scheibenbogen has been studying autoantibodies in ME/CFS for several years

During exercise the body also needs to send blood to the active areas and shunt it away from non-exercising areas. The arteries clamp down to send the blood forcefully to the small blood vessels in the muscles which in turn must open to receive and use the large quantities of blood they need. This process of clamping down on the blood vessels in one end and opening them up on the other is called “functional sympatholysis”.

The authors believe that the heightened sympathetic nervous system activity clamps down hard on the arteries. Meanwhile the B2AdR dysfunction impairs the ability of the small blood vessels to dilate. This dysbalance between vasoconstrictor and vasodilator forces – with the vasoconstrictors winning – triggers the release of  painful vasodilating substances in an attempt to open the blood vessels. The entire process is, in turn, enhanced by the metabolic/energetic problems in the muscles.

In what appears to be a rough blood vessel equivalent  (i.e. leaky small blood vessel syndrome?) this enormous production of vasodilators leak into the interstitial spaces found between the blood vessels, the lymph and the cells.  This happens because one of them, bradykinin,  also happens to be pretty good at enhancing microvascular (small blood vessel) permeability. So now you have some potent peptides in a place they shouldn’t be – which is always a recipe for problems.

Throw that together with a balky energy production system in the muscles and you have a three way mess. The muscles aren’t, in what appears to be a low oxygen (hypoxic) environment, producing enough energy. The bigger blood vessels, on the other hand, are clamped down tight. The small blood vessels stuck in the middle pump out scads of vasodilators which, when they leak out into the tissues exact a price.

This process occurs in dysmenorrhea (menstrual cramps) when tissues in a hypoxic (low oxygen) and hyper-contracted uterus pour vasodilators into the blood causing fatigue, flu-like symptoms, fever, pain and even the sleep disturbances. (Dysmennorhea or endometriosis has been found increased in ME/CFS.)

The situation is a little different in ME/CFS – the authors believe it’s the blood vessels that are in a hypercontractile state – not the muscles. In fact, with the vasodilators pouring out, the authors don’t believe the muscles in ME/CFS are necessarily in a strongly hypoxic state at all.

If a hypercontractile or hypoxic uterus sounds bad, though, consider what hypoxic, hypercontractile blood vessels in the skeletal muscles across the body might be like – maybe something like ME/CFS.

Weird Cardiovascular Findings

The authors propose that  ß2AdR dysfunction could also be responsible for the weird cardiovascular situation found in ME/CFS. Calling the cardiovascular findings in ME/CFS “unique and not found in any other condition or disease”, the authors listed them: hypovolemia (low blood volume), reduced preload (reduced blood flows to the heart), low cardiac output at rest, small hearts, and the kicker – the low renin-angiotensin-aldosterone system (RAAS) activity.

A big and never answered – and rarely asked – question about ME/CFS is: why is the blood volume low? That brings up another more recently asked but similar question:  why are low venous blood flows to the heart consistently found as well? In other words, where the heck has the missing blood gone?

RAAS - Wikimedia

An underactive RAAS system in ME/CFS is a mystery given the low blood volume present. The authors have an idea why.

It’s a big question. For one thing, low blood volume alone could cause the sympathetic nervous system to go onto hyperdrive and put the vagus nerve (the rest and digest system) to sleep.

The real mystery, though, involves what’s going on with the renin-angiotensin-aldosterone system (RAAS) in ME/CFS. Low blood volumes should automatically activate that system to increase the blood volumes, but paradoxically, instead of being increased, RAAS activity appears to be reduced in this disease.

Because, as noted above, low blood volume sends the sympathetic nervous system into overdrive, the inability of the RAAS to do its job could play a major role in ME/CFS. For some reason the RAAS has hardly ever been looked into in this disease.

Wirth and Scheibenbogen have certainly been looking. They turned, once again, to a vasodilator – bradykinin – for a possible answer. While bradykinin attempts to open the blood vessels, it may also be inhibiting RAAS activity and blood volume enhancement at the same time.

The Spillover Effect

The authors don’t believe that these problems are just happening in the muscles. They believe that just about every symptom in ME/CFS could be caused when vasodilatory substances spill over into the general circulation, around the muscles, the lymph nodes, the gut and the bladder.

Provided that enough of these vasodilatory substances were present, every stress on the cardiovascular system could result in fatigue, pain, flu-like systems etc.

Even mental stress, they believe, could cause pain by triggering the sympathetic nervous system to clamp down further on the blood vessels of the skeletal muscles, causing them to emit vasodilators in an attempt to get more blood, and producing pain, flu-like symptoms, etc. For me, personally, this could explain the muscle pain and flu-like symptoms I often experience simply sitting in a chair while doing mental work.

bradykinin

The authors focused on bradykinin – a vasodilator which can also cause pain and increase vascular permeability

The chief vasodilator  – bradykinin – a seemingly all purpose peptide, could also open the blood-brain barrier, and contribute to the intracranial hypertension, small fiber neuropathy, sleep apnea and sleep problems present. Given the low blood volume and preload failure predicted by the spillover of vasodilatory substances, orthostatic intolerance (trouble standing) would be a natural outcome.

An add-on factor in ME/CFS may be a dysfunction of the endothelial cells lining the blood vessels. Autoantibodies to B2AdR receptors could be keeping the blood vessels in ME/CFS from dilating enough.

The chronicity of it all could play a role as well. Given enough cardiovascular stress the B2AdR receptors will simply disappear.

A local TV report triggered Klaus Wirth's interest in ME/CFS

A local TV report triggered Klaus Wirth’s interest in ME/CFS

Mystery Man

But what about Klaus Wirth? We’ve never heard his name before, yet here he is the co-author of a major hypothesis paper on ME/CFS. Wirth, it turns out, an experimental pharmacologist focused on cardiovascular research in Sanofi-Aventis Deutschland in Frankfurt.

During his investigations into small blood vessel diseases he realized how important activation of the beta adrenergic receptors were for blood flows through both the small and large blood vessels. In 2018 his work suggested that beta adrenergic activation plays a vital role in brain blood flows.

Then in March 2018 he happened to turn on a TV show:

In March 2018 I saw a short report on our local TV on a father whose son was bedridden by ME/CFS. He was interviewed for his activities in politics to enhance funding for ME/CFS research. I had no idea of what ME/CFS was and I made a Google search that evening. Next day I went into pubmed. The second abstract I saw was that of Carmen’s group on autoantibodies against ß2-adrenergic receptors. I immediately felt that there might a problem with cerebral and skeletal muscle perfusion and a fundamental and underlying cardiovascular problem. Although I immediately felt that I might be able to understand the pathophysiology it was very tiring to put the pieces of this puzzle together. It took us 1-1.5 years.

Conclusion

Given the vast reach of the cardiovascular system it’s a natural place to look for a cause of ME/CFS, but nobody has looked at it in ME/CFS patients in quite this way before. Banking on studies showing that autoantibodies to the B2AdR receptors are present in a significant subset of ME/CFS patients, the authors draw a vast model of cardiovascular dysfunction which could produce many, if not all, of the symptoms of ME/CFS.

At its core the hypothesis is simple – there’s an imbalance between vasoconstriction and vasodilation in the blood vessels. It starts with a vasoconstriction crunch produced by an overactivated sympathetic nervous system. Damage to BSAdR receptors leaves the small blood vessels near the muscles struggling to open up enough to get the blood they need. With limited blood flows, and with the energy deprived muscles screaming for more blood, the authors envision pain and fatigue provoking vasodilators pouring out in an attempt to open up those blood vessels.

So many vasodilators pour out that they get into the general circulation and leak into the interstitial spaces – the spaces between the blood vessels, the lymph and the tissues – causing pain, fatigue and other symptoms – as well as low blood volume, preload failure and sympathetic nervous system hyperactivity.

One vasodilator, bradykinin, may be responsible for a host of effects including the inability of the renin-angiotensin-aldosterone system to increase blood volume to the proper levels, intracranial hypertension, small fiber neuropathy, sleep apnea and sleep problems.

It’s a grand, unifying hypothesis, indeed. The authors, in fact, see three mechanisms by which these beta adrenergic receptors could be damaged in ME/CFS:  autoantibodies (autoimmune attack), polymorphisms (e.g. mutations) in the gene that produces the receptor, and desensitization to chronic cardiovascular stress. Plus, problems with the endothelium (smooth muscle cells lining the blood vessels) or another form of vascular dysfunction could also strongly contribute.

Stay tuned. A second hypothesis paper focusing on the energy problems in the muscles is coming.

A Never-Ending Immune Battle in ME/CFS? The Regulatory T-cell / Herpesvirus Hypothesis

The failed Rituximab trial might seem like the death knell for autoimmunity in chronic fatigue syndrome (ME/CFS) but it’s not – not by a long shot. While the B-cells that Rituximab targeted are at the heart of much autoimmunity, T-cells can also cause autoimmune diseases. They also play a very important role in stopping infections.

Nuno Sepulveda

Once Sepúlveda, a theoretical immunologist, learned about ME/CFS he knew he had to be involved.

This interesting paper, conceived and led by a Portuguese researcher named Nuno Sepúlveda, PhD suggests that both options are on the table in ME/CFS. He proposes that a battle between a subset of T-cells called regulatory T cells (Tregs) and herpesviruses may be causing ME/CFS.

Nuno Sepúlveda’s PhD is in theoretical immunology, and he’s on the faculty of the London School of Hygiene and Tropical Medical.

The study, the third Sepúlveda has co-authored on ME/CFS, is the tale of both a new hypothesis and a new researcher entering the field.

I asked Sepúlveda how he got involved.

My interest in ME/CFS and the conception of this research came a bit by chance as most things in life. I am a statistician by training but I did a PhD project on theoretical immunology in Gulbenkian Institute for Science in the outskirts of Lisbon. In my PhD theory (supervised by Dr Jorge Carneiro, second author of the paper), I developed mathematical theories on how regulatory T cells regulate autoimmunity throughout life; these cells are thought to be master regulators of the adaptive immune system.

In my post-doctoral research, I was a statistical geneticist and a biostatistician doing research in genetics, immunology and epidemiology of tropical and infectious diseases.

Along the way I met Luis Nacul and Eliana Lacerda (we are all from the same faculty/institution) who asked me to help them with the statistical analysis of UK biobank data.

One day I came across a review paper about autoimmunity and ME/CFS, and I got amazed that no one had done a comprehensive assessment of the role of regulatory T cells on ME/CFS.  So I thought to resuscitate my old work on regulatory T cells and give it a go. Then I got hooked up in the field.

We can see how this field widens. Luis Nacul PhD, the senior author of the study, has spent much of his career deeply embedded in ME/CFS. The former leader of the CureME team at the London School of Hygiene and Tropical Medicine, as well as the UK ME/CFS biobank, Nacul is now the Medical and Research Director of the Complex Chronic Diseases Program at BC Women’s Hospital in Vancouver, Canada. He enrolled Sepulveda in taking on ME/CFS.

The Model

“Given this observation, one can hypothesize that these (ME/CFS) patients might be healthy individuals who, by chance, were infected with a microorganism with a strong molecular mimicry to a human protein.” Sepúlveda et. al.

Nuno Sepúlveda 1 2Jorge Carneiro 3Eliana Lacerda 4Luis Nacul 4 Myalgic Encephalomyelitis/Chronic Fatigue Syndrome as a Hyper-Regulated Immune System Driven by an Interplay Between Regulatory T Cells and Chronic Human Herpesvirus Infections. Frontiers in Immunology.   eCollection 

The story begins with the infectious onset that many people with ME/CFS experience. The ferocious immune response that pathogens evoke puts a strain on the immune system’s regulatory processes. The “policeman” of the immune system  – the regulatory T or Treg cells – are tasked with ensuring that the immune system in its frenzy doesn’t run amok and start attacking the human body.
Regulatory T-cell (Treg) (red) cosying up to an antigen (blue)

Regulatory T-cell (Treg) (red) cosying up to an antigen (blue)

It’s an inexact science. As with any complex system, the immune system walks a fine line between too much and too little regulation. Too much suppression by the Tregs will impair the immune system’s ability to fight off invaders, while too little suppression could result in autoimmunity. Each of us is genetically predisposed one way or the other.

People genetically predisposed to more Treg activity would be better at suppressing autoimmunity, but they might also be more prone to letting infections flourish when their Treg cells mistake the pathogenic antigens as self –  and call off the immune response.

Other individuals predisposed to less Treg activity might be more effective at wiping our pathogens, but more prone to developing autoimmunity. (Since infections, evolutionarily speaking, are more destructive, the authors believe this subset might be more prevalent.)

The big question is where do people with ME/CFS fit in?  On the one hand, many of their symptoms mimic those found in autoimmune diseases – suggesting they may be immunologically predisposed to have an overly strong immune response to pathogens but are poor regulators of that response.

On the other, many people come down with ME/CFS in response to an infection – which suggests they weren’t all that good at fighting off pathogens.

The Third Way – the ME/CFS Way?

There is a third way, though – a kind of a worst of both worlds way –  and that’s what this group’s mathematical modeling, the first of its kind done in ME/CFS, uncovered. If the authors are right it could explain why people with ME/CFS are in such a fix.

The Herpesviruses

The authors demonstrated how such a situation could happen by modeling the effect of herpesviruses on the T regulatory cells in ME/CFS in different immunological contexts.

HHV-6

Using HHV-6, the authors proposed that an ME/CFS state could occur when a smoldering infection is responded to by a T-cell clone with a high potential for producing an autoimmune state.

T-cell clones are populations of T-cells which contain both T regulatory cells and T effector (helper) cells.  Because their composition reflects the immune milieu around them, a T-cell clone with a high autoimmune potential reflects a T-cell clone existing in an environment loaded with self-antigens; i.e. antigens from a pathogen which look like they come from humans. In this example, an HHV-6 infection producing many self-like antigens is present.

Because the infection is smoldering and the viral load is low, though, the full T-helper immune response which would serve to stop the infection is not initiated.  Nor do the T regulatory cells fully step in to ward off an autoimmune response.

Instead, the virus, replicating slowly, triggers both responses. As the Treg cells tamp down the chronic immune response, they also shut down the the cytotoxic NK cells. With the immune system not geared up in either direction, the smoldering infection continues in perpetuity causing high energy costs as well as inflammation and fatigue, and there you have it – a metabolically exhausting state of inflammation and fatigue; i.e. ME/CFS.

Epstein-Barr Virus

A similar situation may occur with EBV when a Treg clone with a high autoimmune potential co-occurs with a low T-cell killing rate.  Instead of a blatant autoimmune response that racks the body, or an effective response to the pathogen, you get partial amounts of both: you get both a sucky immune response to a pathogen AND an autoreactive reaction.  If the authors are right it’s no wonder ME/CFS is such a puzzle and so difficult to treat.

How do the authors believe this shows up biologically? In a high density of and increased percentage of Treg cells in ME/CFS patients compared to healthy controls and people with autoimmune diseases. That’s actually what they see in their ME/CFS patients in their lab.

Different Roads Taken

Interestingly, the authors believe both autoimmune diseases and ME/CFS start off the same path – both are triggered by the cumulative effects of an autoreactive response to a common viral infection – but then both flit off on different paths.

Treg cells immune response

The ways Treg cells tamp down the immune response

Herpesviruses may be setting off autoimmune reactions in both autoimmune diseases and ME/CFS, but in ME/CFS the Treg cells kick in to dampen down the autoimmune response.

Unfortunately, as they’re doing that they’re also bollixing up the immune response to the pathogen – leaving ME/CFS patients in the strange state of both defending against a pathogen and trying to dampen down an autoimmune response at the same time – a metabolically exhausting situation.

The authors believe that a genetic predisposition affecting T-cells would probably be present in ME/CFS, and pointed to genetic polymorphisms that have been found.  Defective T-cell responses to Epstein-Barr Virus have also been found in ME/CFS. Further study of the T-cell repertoires in ME/CFS are needed, though, as well as studies to validate whether Treg density and percentages are increased in ME/CFS.

T-cells – perhaps the single most impactful immune cell in the body – have become the focus of interest of a number of other ME/CFS researchers including Derya Unutmaz at the Jackson Labs, and Mark Davis at Stanford.

Smoldering viral infections have also become a hot topic in ME/CFS. Bob Naviaux and Bhupesh Prusty propose a smoldering HHV-6 infection, and Marshall Williams proposes a smoldering Epstein-Barr infection may be present in ME/CFS, as well.

A Further Widening Field

The “widening” of the ME/CFS field is continuing with Sepúlveda. When I asked him what he’s working on next he reported he was bringing new researchers (and new funders) into the field as well. His research into this possible aspect of ME/CFS is continuing full-bore.

Currently I have a PhD student working full time on a project extending some ideas about the role of regulatory T cells on ME/CFS. This project is funded by the Portuguese Foundation for Science and Technology and my student is doing his research in the Molecular Medicine Institute in Lisbon. I am also trying to find/identify candidate molecular mimicries between viruses and human proteins that could explain 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

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.

 

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)

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

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

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

UK ME/CFS Biobank

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

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

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

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

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

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

The Study

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

The Patients

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

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

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

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

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

Results

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

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

MAIT cells

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

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

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

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

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

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

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

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

Slight Increase in ESR Surprises

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

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

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

Natural Killer Cells

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

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

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

NK cell functioning

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

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

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

Exhausted T-cells?

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

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

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

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

Conclusion

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

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

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

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

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

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

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

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

Ugandan Village

Ugandan Village (from the NIH)

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

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

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

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

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

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

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

Leiomodin-1 staining neurons

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

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

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

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

autoimmune responses ME/CFS

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

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

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

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

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

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

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

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

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

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

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

Technology Paves the Way

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

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

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

Check out an interview with Dr. Nath

Dr Nath Talks on the ME/CFS NIH Intramural Study

The NIH’s Accelerating Research on ME/CFS Conference

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

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

Learn more about the NIH Conference below.

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

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

Robert’s Story

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

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

ME/CFS diagnosis

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

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

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

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

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

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

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

Metabolic Chamber

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

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

metabolic chamber NIH

An early metabolic chamber at the NIH in 1957

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

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

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

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

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

Brain Scan

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

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

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

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

rTMS Test

motor cortex

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

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

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

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

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

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

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

NIH intramural ME/CFS study data collection

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

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

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

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

Participating in the Study

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

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

Find out how to participate here.

Learn more about the Intramural Study

Dr Nath Talks on the ME/CFS NIH Intramural Study

Dr Nath Talks on the ME/CFS NIH Intramural Study

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

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

 

NIH

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

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

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

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

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

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

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

The NIH Intramural ME/CFS Study

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

Dr. Nath

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

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

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

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

The NIH Intramural Chronic Fatigue Syndrome Study

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

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

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

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

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

community ME/CFS

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

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

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

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

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

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

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

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

High Percentage of Rare Diseases 

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

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

Big Data

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

rare disorder chronic fatigue

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

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

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

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

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

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

No Preliminary Findings Yet

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

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

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

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

The Study

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

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

muscles ME/CFS

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

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

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

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

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

Participating in the Study

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

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

Find out more here.

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

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