Chronic Fatigue Syndrome: Evaluation of a 30-Criteria-Score and Correlation with Immune Activation

Transcription

1 Chronic Fatigue Syndrome: Evaluation of a 30-Criteria-Score and Correlation with Immune Activation Arnold Hilgers, MD Johannes Frank ABSTRACT. Objective: The develoment of a score for severity of Chronic Fatigue Syndrome (CFS), the correlation of CFS with arameters of immune activation and the association with athogens. Methods: Five hundred five atients with susicion of Chronic Fatigue Syndrome and no other definitive diagnosis were checked by a 45-criteria-score, basic laboratory rograms and immunological rofiles. In most of the atients further tests concerning comlement system, immune activation markers, hormones and serology of heres viruses, Chlamydia and Borrelia could be evaluated. Comarison of the symtoms of CFS atients with healthy controls lead to a 30-criteria-score and this score was correlated with laboratory arameters (Searman rankcorrelation-coefficient r s, ties corrected). Results: Three hundred eighty-five atients fulfilling stronger criteria according to the Centers for Disease Control (CDC) definition showed significant differences to 53 healthy controls in 40 of the 45 criteria ( < 0.001, twitches and food allergies < 0.05). Thirteen symtoms corresonding to CDC criteria were all significant ( < 0.001), 17 further significant criteria of descending recision were added; resiratory infections, alitations, dizziness, dysesia, dryness of mouth/eyes, allergies, nausea, aresthesia, loss of hair, skin alterations, dyscoordination, chest ain, ersonality changes, eczema, general infections, twitches, urogenital infections. A correlation between the 30-criteria-score and immunological arameters could be evaluated in 472 of the 505 atients. Significant ositive correlation with the 30-criteria-score was found in numbers of CD8+ T-lymhocytes, HLA-DR+ T-lymhocytes, gamma globulins, IgM, IgG, and for the number of tye of autoantibodies (mainly ANA, ACA, antithyroid and antiarietal cell antibodies). Significant negative correlation was found in albumin-globulinratio, eosinohils and IgE. Most of these arameters also correlated with one another. On the other hand, in subgrous of the 505 atients the frequency of ositivity in serological tests for HHV-6 (49.9%), EBV (35.4%), HSV (29.2%), CMV (12.5%) and Chlamydia (35.0%) was striking. Borrelia Western blots showed 3 or more secific IgG-bands in 54 of 131 atients. (41.2%). In some cases infection with EBV, HHV-6 and CMV, resectively, was confirmed by DNA-PCR-test and antigen detection. Summary: In increasingly larger grous of atients with CFS and related constellations we often see clinical signs and longer anamnesis of other symtoms besides the classical criteria of CFS, esecially a high revalence of local and general suscetibility to infections and hints to rolonged inflammation rocesses. Together with other results, the data confirm the hyothesis that a reduced or unstable immune control or delayed immune reaction to ersisting viruses or bacterial intracellular athogens, ossibly triggered by common infections or other environmental factors, can lead to a chronic neuro-immune activation state and auto-immune disorders. Hyersensitivity symtoms of the atients might not be mediated by classical allergies alone but also result from a tye-iv-hyersensitivity. [Article coies available for a fee from The Haworth Document Delivery Service: address: getinfo@haworth.com] KEYWORDS. Chronic Fatigue Syndrome, immune activation, athogens, hyersensitivity Arnold Hilgers and Johannes Frank are affiliated with the Institut für angewandte Immunologie und Umweltmedizin, Duisburger Str. 7, D Düsseldorf, Germany. Address corresondence to Dr. Arnold Hilgers, Institut für angewandte Immunologie und Umweltmedizin, c/o Golzheimer Platz 5, D Düsseldorf, Germany. Journal of Chronic Fatigue Syndrome, Vol. 2(4) by The Haworth Press, Inc. All rights reserved.

2 INTRODUCTION Fatigue and exhaustion are tyical leading symtoms of atients with Chronic Fatigue Syndrome (CFS), but they are often accomanied by various other symtoms. Furthermore, by definition of the Centers of Disease Control (CDC) (1,2), other known disease entities must be excluded when using the diagnosis of CFS. In our exerience and according to the results of other investigators (3), there is an association between the clinical condition of CFS and immunological disorders, which led to the term "Chronic Fatigue Immune Dysfunction Syndrome" (CFIDS). The aim of our resent study was to investigate the ossibility of a correlation between the severity of Chronic Fatigue Syndrome and laboratory arameters indicating an immune dysfunction often described as athological in atients with CFS. PATIENTS AND METHODS The basic grou consisted of 505 atients with susicion of CFS and no other definitive diagnosis. Two hundred eighty-eight atients were female, 217 male, the mean age was 42 years (standard deviation 13 years) and the range 8-78 years. All atients consulted the same medical office, which had secialized in chronic immunological disorders and CFS for many years. The duration of illness was several years in nearly all cases. Most atients had undergone various excluding diagnostic tests, esecially sychiatric examinations, and had frequently received several sychiatric or sychosomatic treatments. All atients were assessed clinically and examined by basic laboratory rograms. Furthermore, immunological and serological rofiles were established. In addition, the clinical status of the atients was evaluated according to a 45-criteria-score that included 15 criteria corresonding to CDC criteria and other criteria based on symtoms observed in our CFS atients, esecially clinical signs indicating ossible immune dysfunction, infections and allergies. To get an adequate measuring scale of the severity of the Chronic Fatigue Syndrome, 385 of the 505 atients who fulfilled the most recent CDC criteria were comared in all 45 criteria with 53 healthy control ersons by the statistical test of Kolmogoroff and Smirnov. Furthermore, the symtoms were ranked in descending order according to calculated recision. From that list the first 30 symtoms with a significantly different distribution in comarison to controls led to the 30-criteria-score. In 472 of the 505 atients basic immunological arameters were evaluated: arameters of the cellular immune system were absolute numbers of total leukocytes, neutrohil granulocytes, lymhocytes, monocytes, eosinohilic granulocytes, basohilic lymhocytes, T-lymhocytes (CD3), B-lymhocytes (CD19), suressor/cytotoxic T-cells (CD8), heler/inducer T-cells (CD4) and activated T-cells (HLA-DR); arameters of the humoral immune system were absolute serum levels of total rotein, albumin, alha-i-globulin, alha-2-globulin, beta-globulin, gammaglobulin, albumin-globulin-ratio, and immunoglobulin A (IgA), M (IgM), G (IgG) and E (IgE). Autoimmunity assessment included testing for antinuclear (ANA), antimitochondrial (AMA), anti-dna and anti-cardioliin antibodies (ACA) and, deending on clinical symtoms, additionally for antithyroid, anti-arietal cell, myocardial and neuronal antibodies. From smaller grous, serological, hormonal and further arameters were also available. Serology covered heres viruses (EBV-VCA-IgG, EBV-early antigen, EBV-EBNA and the EA/EBNA-ratio, HHV-6- IgG, HSV-KBR, VZV-KBR, CMV-KBR), Chlamydia (Chlamydia-IgA) and Candida (Candida antibodies). Hormonal status covered thyroid hormones T3, T4 and basal TSH, cortisol, FSH, LH/ICSH and rolactin. Further arameters concerned comlement system (CH-50 comlement activity, C3 comlement factor and C4 comlement factor) and immune activation markers such as cytokines (serum levels of soluble interleukin-2-recetor [sil-2-r], tumor necrosis factor alha [TNF-alha), neoterin, beta-2-microglobulin) and circulating immune comlexes. Every laboratory arameter was correlated with the 30-criteria-score by the Searman rank correlation coefficient r s, ties corrected. In the case of autoimmunity, the number of different auto-antibody tyes was used. Indeendent of the correlation, the frequencies of serological abnormalities concerning Human Heres Virus Tye 6 (HHV-6-IgG), Estein Barr Virus (EBV-early antigen antibodies), Heres Simlex Virus (HSV-KBR), Cytomegalo Virus (CMV-KBR) and Borrelia burgdorferi (Western blot) were recorded. In cases where susicion of an active infection with EBV, CMV or HHV-6 was articularly strong, the diagnostics were comlemented by PCR-test and antigen detection in blood leucocytes.

3 Original Articles RESULTS The 385 atients who were comared with 53 healthy control ersons regarding 45 symtoms showed significant differences in 40 symtoms, 38 of which were highly significant ( < 0.001). The list of the first 30 significantly different symtoms in descending order according to calculated recision led to the 30-criteria-score, which is resented in Table 1 together with the statistical significance. Among the first of these 30 criteria were 13 symtoms corresonding to the CDC criteria: fatigue/exhaustion, lack of concentration, memory disorders, slee disorders, myalgia, swings of mood, headache, deression, haryngitis, nocturnal sweat, arthralgia, visual disorders, and lymhadenoathy. Consequently, 17 further symtoms not belonging to the classical CFS definition were added: resiratory infections, alitations, dizziness, dysesia, dryness of mouth/ eyes, allergies, nausea, aresthesia, hair loss, skin alterations, dyscoordination, chest ain, ersonality changes, eczema, general infections, muscle twitching, and urogenital infections. The calculated recision of the 30 criteria was 95.7%, as comared to 36.3%. TABLE 1. Thirty-Symtoms-Score in CFS-Patients (n = 385) Comared with Control Persons (n = 53) (Statistical Analysis According to Kolmogoroff and Smirnov). Precision of a symtom= ositive in CFS -atients (%) + negative number of CFS -atients in controls (%) Rank Symtom Statistics Precision 1 fatigue/exhaustion < % 2 lack of concentration < % 3 memory disorders < % 4 slee disorders < % 5 myalgia. < % 6 swings of mood < % 7 headache < % 8 resiratory infections < % 9 deression < % 10 alitation < % 11 dizziness < % 12 haryngitis < % 13 dysesia < % 14 nocturnal sweat < % 15 arthralgia < % 16 dryness of eye/mouth < % 17 visual disorders < % 18 allergy < % 19 nausea < % 20 aresthesia < % 21 hair loss < % 22 lymhadenoathia < % 23 skin alterations < % 24 dyscoordination < % 25 chest ain < % 26 ersonality changes < % 27 skin rashes < % 28 general infections < % 29 muscle twitching < % 30 urinary infections < %

4 The following arameters were ositively correlated with CFS severity: in th e cellular immune system, numbers of CD8 T-cells (suressor/cytotoxic cells) and HLA-DR ositive T-cells (activated T-cells) (Table 2); in the humoral immune system, gamma-globulin, serum-igm and serum-igg levels (Table 3), and number of autoantibody tyes. Negatively correlated arameters included eosinohilic granulocytes, serum level of IgE and albumin-globulin ratio (Table 2 and 3). TABLE 2. Parameters of the Cellular Immune System in Correlation with CFS (n = 472). Parameter Searman-rank- (absolute number of cells) correlation leukocytes neutrohile granulocytes lymhocytes monocytes eosinohilic granulocytes basohilic granulocytes T-lymhocytes (CD4) B-lymhocytes (CD 19) suressor/cytotoxic T-cells (CD8) heler/inducer T-cells (CD4) activated T-cells (HLA-DR) NK cells (CD 16 CD56) immune ratio (CD4/CD8) All of these correlations were shown to be significant; most of the arameters also correlated with one another (Table 4). For other investigated arameters of the immune system (serology, hormones, c omlement system and activation markers), no correlation with CFS could be statistically confirmed (Tables 5 and 6). In subgrous of the 505 atients, the frequency of ositivity in serological tests for the following athogens was striking: HHV-6-IgG in 243 of 487 atients (49.9%), EBV-EA in 170 of 480 (35.4%), HSV-KBR in 135 of 462 (29.2%), CMV-KBR in 49 of 390 (12.5%), and Chlamydia-IgA in 142 of 406 (35.0%). Western blot of Borrelia burgdorferi showed 3 or more secific IgG-bands (83, 41, 34, 31, 25, and 21) in 54 of 131 atients (41.2%). DISCUSSION Clinical symtoms and chronic course of Chronic Fatigue Syndrome already suggested disordered immune function in many of our atients. Classical CFS criteria alone may lead to a broader sectrum of os sible underlying athomechanisms including sychological comonents. In nearly all of our atients, additional symtoms such as suscetibility to infections, recurrent infections, signs of allergies and hyersensitivity were found. This may be due to some kind of selection, because in most atients revious treatment had failed and immunological and infectious asects of their disease may not have been realized or checked before in detail. All the immunological arameters showing ositive correlation with the severity of the Chronic Fatigue Syndrome in our atients can be found elevated in connection with an activated immune system and infections. Formerly ublished data regarding our CFS atients (4,5) and results of other investigators (6-8) document elevation of CD8+ lymhocytes and T-cell suboulations exressing activation markers (HLA-DR, CD28, CD38). Patarca et al. (9-11) found significant ositive correlations with other immunological arameters. Also abnormalities of humoral immune resonse and autoantibodies in CFS atients were reorted (12).

5 TABLE 3. Parameters of the Humoral Immune System in Correlation with CFS (n = 472, for IgE n = 264). Parameter (absolute values of roteins) Searman-rankcorrelation total serum-rotein albumin alha-1-globulin alha-2-globulin beta-globulin gamma-globulin albumin-globulin-ratio IgA lgm IgG IgE Although other arameters, articularly factors of the comlement system, immune activation markers and serological tests for various infectious agents were found abnormal in many of our CFS atients, in the certainly heterogeneous total grou no other correlation with the severity of CFS could be statistically confirmed. TABLE 4. Immune Parameters Positively Correlating with CFS-30-Symtoms-Score and with One Another. CD8+ cells act. T-cells gamma globulins 30- symtomsscore albuminglobulin-ratio IgM IgG CD8+ cells (0.036) act. T-cells (0.032) gamma globulins (0.016) (0.106) (0.002) albumin-globulin-ratio (0.014) (0.018) IgM (0.001) (0.058) (0.399) IgG (0.029) (0.162) (0.029) number of autoantibodies (0.003) (0.405) (0.012) (0.048)

6 TABLE 5. Serological Parameters in Correlation with CFS. Parameter n Searman-rankcorrelation EBV-VCA-IgG EBV-EA EBV-EBNA EA/EBNA-ratio HHV-6-IgG HSV-KBR VZV-KBR CMV-KBR Chlamydia-IgA Candida-HT TABLE 6. Hormones and Further Immunological Parameters in Correlation with CFS. Parameter n Searman-rankcorrelation T T TSH-basal cortisol FSH LH/ICSH rolactin CH-50-comlement C3-comlement factor C4-comlement factor sil-2-r TNF-alha neoterin beta-2-microglobulin circulating immune comlexes

7 An exlanation for this could be that the level of comlement factors, cytokines and antibodies against secific athogens may fluctuate and temorarily eak, while the correlating arameters reresent th e global tendency of immune activation, just as the clinical definition of CFS summarizes symtoms over a longer time eriod. It has to be assumed that the clinical state of Chronic Fatigue Syndrome can result from a variable immune dysfunction, deending on the individual immunological resonse, the articiating antigens and the chronic course. The common feature of a chronically activated immune system and the comlex immune dysbalance may be more associated with the clinical symtoms than with secific infectious agents. These may more likely lay a role of triggering and can be variable in the individual atient. Heres virus infections, in articular EBV infection, were reeatedly found in atients with CFS. Although in earlier studies abnormalities of serology, articularly ersisting or recurrent ositive Early-Antigen-antibodies and low EBNA-antibodies, were reeatedly described (13), we could confirm Estein-Barr Virus in growing numbers of CFS atients by ositive EBV-PCR and EBV-antigen detection; in single case (CMV-PCR and/or CMV antigen, resectively) HHV-6-PCR was detectable (unublished data). Several mechanisms of interference with immune resonse associated with heres virus, esecially EBV, were also detected, articularly in suscetible individuals (14,15). Additionally, bacteria, articularly ersisting intracellular athogens such as Chlamydiae and Borreliae, may lay a role in immune activation. Without resenting the classical clinical icture of Borreliosis or other criteria justifying main diagnosis of Borreliosis, latent and ossibly reactivated Borrelia infection could, however, maintain immune activation in subgrous of CFS atients, esecially since we observed a decrease of secific bands in Western blot that arallels clinical imrovement under secific antibiotic treatment with ceftriaxone. Divergence from the results of other investigators (16) may be due to different strains of Borrelia burgdorferi (17). The ositive correlation with the number of tyes of autoantibodies suggests that with increased CFS disease severity more autoimmune henomena can occur, and thus more organs or organ systems may be involved. Furthermore, CFS must be considered as a otential forerunner of a manifest autoimmune disease. Thus, for examle, we observed manifestations of autoimmune diseases such as Multile Sclerosis after longstanding CFS associated immune dysfunction. On the other hand, retrosective anamnesis of our atients with manifest autoimmune diseases such as Multile Sclerosis, rheuma tic diseases, autoimmune thyroiditis, ulcerative colitis, Chron's disease, and Systemic Luus Erythematodes (SLE) frequently reveals eriods of CFS or similar symtoms long before the diagnosis of autoimmune disease was established. The discussed athogens could also be involved in the develoment of autoimmune rocesses (18). In site of marked clinical symtoms of hyersensitivity, which leads to an overlaing between CFS and Multile Chemical Sensitivities (MCS) (19), our data show negative correlatio n between the severity of CFS and numbers of eosinohilic cells and IgE that are found in classical allergy reaction (tye-i-immunoreaction according to Gell and Coombs) suggesting that allergies may not be causative for all the symtoms. A recent finding in our atients is a marked tye-iv-hyersensitivity of T-lymhocytes, articularly against common food roteins (unublished data), which could be an exlanation for many clinical symtoms. Furthermore, non-infectious antigens or allergens could amlify the antigen rocessing load and thus maintain immune stimulation. CONCLUSIONS The association of a chronically stimulated immune system in atients with symtoms of Chronic Fatigue Syndrome and the ositive correlation between severity of the clinical syndrome and immunological arameters show that the disturbed immune resonse has to be focused more than single athogens. The comlex interactions between athogens and their host that can lead to latency, ersistence and reactivating of the infection must be considered in the sense of evolution: by rotecting themselves from the defensive mechanisms of the human organism, viruses, bacteria and other microorganisms ensure their own survival and thereby eretuate the infection. On the other hand, hints of various infectious antigens, articularly the serological findings, could also be a form of co-activation in the course of immune activation without contribution for athogenesis. The central question of "Who's Who?" or "culrit or witness" for the ossible athogenetic factors of CFS cannot be answered for the grou in total but must be differentiated for subgrous, esecially from the immunological oint of view. In this way diverse diseases underlying CFS have to be characterised more clearly on the basis of different tyes of immune dysfunction.

8 Deending on the sectrum of latent infections, a mixed combination of athogen activities is also ossible. Additionally, non-infectious antigens such as food roteins and chemical substances such as ollutants, maintaining immune stimulation by tye-iv-hyersensitivity, should be taken into account. Our exerience suggests that otimal treatment both for CFS and for other chronic diseases must be determined by a better understanding of the underlying level of immune disorder, cytokine attern, and triggering factors such as athogens and food roteins. REFERENCES 1. Holmes GP, Kalan JE, Gantz NM, Komaroff AL, Schonberger LB, Straus SE, Jones JF, Dubois RE, Cunningham-Rundles C, Pahwa S, Tosato G, Zegans LS, Purtilo DT, Brown N, Schooley RT, Brus I. Chronic fatigue syndrome: a working case definition. Ann Int Med. 1988;108 (3): Fukuda K, Straus SE, Hickie I, Share MC, Dobbins JG, Komaroff A. International CFS Study Grou. The Chronic Fatigue Syndrome: A Comrehensive Aroach to Its Definition and Study. Ann Int Med. 1994; 121 (12): Patarca R, Fletcher MA, Klimas NG. Immunological correlates of chronic fatigue syndrome. In: Goodnick PJ, Klimas NG, eds.: Chronic Fatigue and Related Immune Deficiency Syndromes. Washington-London: American Psychiatric Press, 1993: Hilgers A, Frank J. Chronic Fatigue Immundysfunction Syndrome bei 103 Patienten: Diagnostik, Befunde und Theraie. Z Klin Med. 1992;47 (4): Hilgers A, Frank J. Chronic Fatigue Syndrome: Immundysfunktion, Erreger- und Schadstoffbeteiligung sowie neurologische und kardiale Veränderungen. WMW. 1994; 144 (16): Landay AL, Jesso C, Lennette ET, Levy JA. Chronic fatigue syndrome: clinical condition associated with immune activation. Lancet. 1991;338: Ho-Yen DO, Billington RW, Urquhart J. Natural killer cells and the ost viral fatigue syndrome. Scand J Infect Dis. 1991;23: Klimas NG, Salvato FR, Morgan R, Fletcher MA. Immunologic abnormalities in chronic fatigue syndrome. J Clin Microbiol. 1990;28 (6): Patarca R, Lugtendorf S, Antoni M, Klimas NG, Fletcher MA. Dysregulated exression of tumor necrosis factor in the chronic fatigue immune dysfunction syndrome: Interrelations with cellular sources and atterns of soluble immune mediator exression. Clin Infec Dis. 1994;18:S1147-S Patarca R, Klimas NG, Garcia MN, Walters MJ, Dombroski D, Pons H, Fletcher MA. Dysregulated exression of soluble immune recetors in a subset of atients with chronic fatigue syndrome: cross-sectional categorization of atients by immune status, J Chronic Fatigue Syndrome. 1995; 1 (1): Patarca R, Klimas NG, Sandler D, Garcia MN, Fletcher MA. Interindividual immune status variation atterns in atients with chronic fatigue syndrome: association with the tumor necrosis factor system and gender. J Chronic Fatigue Syndrome, 1995; 2 (1): Buchwald D, Komaroff AL. Review of Laboratory Findings for Patients with Chronic Fatigue Syndrome. Rev Infect Dis. 1991;13 (su 11):S12-S Straus SE, Tosato G, Armstrong G, Lawley T, Preble OT, Henle W, Davey R, Pearson G, Estein J, Brus I, Blaese M. Persisting illness and fatigue in adults with evidence of Estein-Barr virus infection. Ann Int Med. 1985; 102: Vento S, Guella L, Mirandola F, Cainelli F, Di Perri G, Solbiati M, Ferraro T, Concia E. Estein -Barr virus as a trigger for autoimmune heatits. in suscetible individuals. Lancet. 1995;346: Straus SE. Studies of heresvirus infection in chronic fatigue syndrome. In: Chronic fatigue syndrome. Wiley, Chichester (Ciba Foundation Symosium 173), 1993: Pollack RJ, Komaroff AL, Telford SR, Gleit M, Fagiolo L, Burnet LR, Sielman A. Borrelia burgdorferi infection is r arely found in atients with Chronic Fatigue Syndrome. Clin Infect Dis 1995;20 (2): Lyme disease: the American divide. Conference reort by D. Wright. Lancet 1994; Kotb M. Infection and autoimmunity: a story of the host, the athogen, and the coathogen. Clin Immunol Immunoathol. 1995;74 (1): Buchwald D, Garrity D. Comarison of Patients with Chronic Fatigue Syndrome, Fibromyalgia and Multile Chemical Hyersensitivities. Arch Intern Med. 1994;154 (9):