All posts tagged TGF-B

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.

 

NEID Disease? Study Suggests Neuro, Endocrine and Immune Systems Work Together to Produce ME/CFS

Bruun Wyller continues to surprise. When last heard from this erstwhile cognitive behavioral therapy (CBT) proponent asserted that more research into Epstein-Barr virus in chronic fatigue syndrome (ME/CFS) was needed. Now he’s looking at the interaction between the immune and endocrine systems.

The Evolution of a Chronic Fatigue Syndrome (ME/CFS) Researcher? CBT Proponent Calls for More Herpesvirus Research

Transforming growth factor beta (TGF-β) in adolescent chronic fatigue syndrome Vegard Bruun Wyller1,2*, Chinh Bkrong Nguyen1, Judith Anita Ludviksen3,4 and Tom Eirik Mollnes. J Transl Med (2017) 15:245 https://doi.org/10.1186/s12967-017-1350-

Wyller begins his new study reporting that systemic inflammation is probably present and B-cell functioning is impaired (if modestly) in ME/CFS, but that the picture regarding cytokines is muddier. A meta-analysis of 38 ME/CFS cytokine studies examining 77 cytokines found only one standout – a cytokine called TGF-B. It was consistently elevated in 2/3rds of the studies.

cytokines chronic fatigue syndrome

Only one cytokine has more or less consistently shown up elevated in ME/CFS studies – TGF-B

Given its unusual and consistent appearance in cytokine study results, why TGF-B has gotten so little attention in ME/CFS is unclear. The fact that it’s kind of a weird cytokine probably doesn’t help. Secreted by macrophages and some other immune cells, TGF-B can function as both an anti and pro-inflammatory cytokine depending on the situation it’s in.

It’s three forms are involved in a multitude of regulatory processes involving inflammation and immunity.  It does more than participate in the immune system; TGF-B also affects or is affected by the two stress response systems in our bodies – the HPA axis and autonomic nervous system. All that makes TGF-B a complex character indeed.

Take our two stress response systems. During stressful situations increased TGF-B levels appear to be associated with increased levels of cortisol – the main stress hormone of the HPA axis.  An ME/CFS study examining the gene expression of immune cells found an abnormally high expression of genes that interact with the HPA axis and autonomic nervous system. That suggested that a significant immune-hormone component is present. Indeed, ME/CFS has long been characterized as a neuroendocrineimmune (NEID) – a disease that effects all three systems.

In this study Wyller, a Norwegian researcher, again used his own broad definition of ME/CFS to find patients, but this time he did post hoc analyses using the Fukuda and Canadian Consensus criteria to determine if different definitions of ME/CFS made a difference – they didn’t). As always, Wyller studied adolescents – a lot of them (n=120) and 68 controls to produce a very nice sized study. The data analysis took a long time; the data itself was collected from 2010-2012.

TGF-B actually comes in three forms ((TGF‑β1, TGF‑β2 and TGF‑β3). For the first time ever in ME/CFS Wyller tested for all three forms of TGF-B, as well as norepinephrine, epinephrine and cortisol (urine) and c-reactive protein (serum).   He also assessed heart rate variability, and in 29 patients examined their whole blood gene expression.  Questionnaires assessing fatigue, inflammatory symptoms, post-exertional malaise, sleep, mood and anxiety were also given.

Results

Wyller expected TGF-B levels to be higher in his adolescent ME/CFS patients, but to his surprise even using the CCC and Fukuda criterias, they were not. Nor was TGF-B associated with any clinical markers such as fatigue, PEM, sleep problems, etc.

cortisol

Wyller suggests an unusual neuroimmune connection involving TGF-beta and stress hormones such as cortisol (pictured) may be present

The study was looking like a bust until Wyller dug a little deeper. It turned out that TGF-B levels were associated with increased levels of the stress hormones cortisol, norepinephrine and epinephrine in the ME/CFS patients but not in the healthy controls.

An unusual immune-endocrine interaction was occurring in ME/CFS patients that was not found in the healthy controls. For some reason, TGF-B  levels rose in conjuction with stress hormones in the ME/CFS patients but not in the healthy controls.  All three TGF-B isoform displayed this association.

Plus that association also correlated with symptom severity. Wyller found that the TGF-B-cortisol-autonomic nervous system correlation was strongest in the most fatigued ME/CFS patients.  Less fatigued ME/CFS patients, on the other hand, had much less of this association.

Once again, context appeared to be king in the ME/CFS patients. The levels of TGF-B didn’t matter but the network they were embedded in did. A similar scenario showed up in the huge cytokine study conducted by Dr. Montoya and Mark Davis of Stanford. That study, like Wyller’s, didn’t find high levels of cytokines, but it did find that even normal cytokine levels affected symptoms. That suggested some sort of immune hypersensitivity, perhaps associated with some unusual network functioning, was present.

Now Wyller apparently finds an immune and autonomic nervous sensitivity to TGF-B. It’s not the cytokine levels themselves but the effect they have on stress hormones.  Indeed, Wyller suggested that the primary disease mechanism in ME/CFS is not altered immune production but altered immune control. Somehow the immune system is affecting other systems in unusual ways.

That’s an intriguing idea given what we’ll shortly see from Dr. Klimas, whose intense testing during exercise suggests that exercise induced immune activity trips off autonomic nervous system problems in ME/CFS. Gordon Broderick’s network studies suggest that cytokine levels don’t need to be high to have untoward effects on ME/CFS patients – they simply have to be embedded in an unusual immune network.

Wyller - neuro-endocrine-immune disease

Wyller believes a complex neuro-endocrine-immune interaction may be contributing to the fatigue and possibly the EBV issues in ME/CFS.

Dr. Klimas will be trying in a series of small studies to move those systems back to normal this year. (More on that later.)

Wyller’s findings suggest that his “sustained arousal” hypothesis may be correct and that the “sustained arousal” he believes is present in ME/CFS is being triggered by the immune system. His small gene expression study possibly bares this out. Wyller warned about reading too much into the gene expression analysis because of the small sample size (n=29). The analysis found, though, that the TGF-B3 isoform was negatively associated with reduced expression of two B-cell genes (TNFRSF13C and CXCR5).

Wyller suggested that TGF-B3 may be altering the effect that cortisol – the master immune regulator – has on B-cell genes in ME/CFS.  If TGF-B and cortisol combine to smack B-cell genes in ME/CFS, Wyller suggests that could translate into problems reining in Epstein-Barr virus (EBV) – a common trigger in ME/CFS.  Wyller’s earlier gene expression study, in fact, suggested that B-cell problems could be the key to the EBV problems seen in ME/CFS. Now Wyller suggests that these B-cell problems could result from a complex interaction between TGF-B and cortisol.

Wyller’s going to check out that interaction in a study which will determine how effectively the B-cells in ME/CFS patients respond to EBV in the presence of neuroendocrine hormones. If cortisol or other neuroendocrine hormones impair the ability of B-cells to whack EBV in ME/CFS, Wyller may have uncovered one reason why mononucleosis is such a common trigger for ME/CFS.

Mold Connection?

Wyller’s focus on the research literature apparently precluded him from exploring another TGF-B angle. Mold has become a hot if little studied topic in ME/CFS. For over a decade, mold doctor Ritchie Shoemaker has asserted that elevated TGF-B levels play a major role in mold related illnesses.  Instead of B-cells, though, Shoemaker ties TGF-B issues to T cell problems and reduced blood flow in the capillaries, which translate into reduced oxygen uptake and problems with producing energy in the mitochondria – a key theme in ME/CFS.

Shoemaker, interestingly, asserts those blood flow and immune problems mirror what is happening in sepsis. In fact, Shoemaker believes that the chronic inflammatory response syndrome (CIRS) he sees in his patients is a chronic form of sepsis. Over ten years ago ME/CFS specialist Dr. David Bell proposed a chronic form of sepsis exists in ME/CFS as well.

Could Chronic Fatigue Syndrome (ME/CFS) Be a Chronic Form of Sepsis?