CONFERENCE ON MYALGIC ENCEPHALOMYELITIS (ME) FOR HEALTH PERSONNEL, June 12, Stavanger University Hospital, Stavanger, Norway

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1 CONFERENCE ON MYALGIC ENCEPHALOMYELITIS (ME) FOR HEALTH PERSONNEL, June 12, 2009 Stavanger University Hospital, Stavanger, Norway ME in 2009 : overview of current scientific data including a study on severely disabled Norwegian patients Kenny De Meirleir, Chris Roelant, Marc Frémont, Kristine Metzger Brussels, Belgium

2 Myalgic encephalomyelitis : Definition, Prevalence CONFERENCE ON MYALGIC ENCEPHALOMYELITIS (ME) FOR HEALTH PERSONNEL, Stavanger, June 12, 2009

3 Holmes criteria, 1988 (1) Major criteria 1. New onset of persistent or relapsing, debilitating fatigue in a person without a previous history of such symptoms that does not resolve with bedrest and that is severe enough to reduce or impair average daily activity to less than 50% of the patient s premorbid activity level for at least 6 months; 2. Fatigue that is not explained by the presence of other evident medical or psychiatric illness Minor Symptom Criteria 1. Mild fever ( C orally) or chills 2. Sore throat 3. Posterior cervical, anterior cervical, or axillary lymph node pain 4. Unexplained generalized muscle weakness 5. Muscle discomfort or myalgia 6. Prolonged (at least 24 h) generalized fatigue following previously tolerable levels of exercise 7. New, generalized headaches 8. Migratory noninflammatory arthralgias 9. Neuropsychiatric symptoms, photophobia, transient visual scotoma, forgetfulness, excessive irritability, confusion, difficulty thinking, inability to concentrate, depression 10. Sleep disturbances (hypersomnia or insomnia) 11. Patient's description of initial onset of symptoms as acute or subacute

4 Holmes criteria, 1988 (2) Physical Examination Criteria Must be documented by a physician on at least two occasions, at least 1 month apart: 1. Low-grade fever ( C orally or C rectally). 2. Nonexcudative pharyngitis. 3. Palpable or tender anterior cervical, posterior cervical, or axillary lymph nodes (< 2 cm in diameter).

5 Fukuda criteria, CFS is clinically evaluated, unexplained, persistent or relapsing chronic fatigue that is of new or definite onset (i.e. not lifelong); the fatigue is not the result of ongoing exertion, is not substantially alleviated by rest, and results in substantial reductions in previous levels of occupational, educational, social, or personal activities. 2. There must be concurrent occurrence of four or more of the following symptoms, and all must be persistent or recurrent during 6 or more months of the illness and not predate the fatigue: 1. Self-reported persistent or recurrent impairment in short-term memory or concentration severe enough to cause substantial reductions in previous levels of occupational, educational, social, or personal activities 2. Sore throat 3. Tender cervical or axillary lymph nodes 4. Muscle pain 5. Multiple joint pain without joint swelling or redness 6. Headaches of a new type, pattern or severity 7. Unrefreshing sleep 8. Postexertional malaise lasting more than 24 hours

6 Canadian definition (1) Fatigue Post-exertional malaise and/or fatigue Sleep dysfunction Pain Two or more neurological/cognitive manifestations: - Confusion - Impairment of concentration and short term memory consolidation - Disorientation - Difficulty with information processing, categorizing and word retrieval - Perceptual and sensory disturbances - Ataxia - Muscle weakness - Fasciculations

7 Canadian definition (2) One or more autononomic/neuroendocrine/immune symptoms: - Orthostatic intolerance/neurally mediated hypotension - Postural orthostatic tachycardia syndrome - Delayed postural hypotension - Light-headedness - Extreme pallor - Nausea - Irritable bowel syndrome - Urinary frequency and bladder dysfunction - Palpitations with or without cardiac arrhythmias - Exertional dyspnea Illness persists for at least six months, usually distinct onset (may be gradual), for children: three months

8 Prevalence and socio-economic cost Prevalence estimates: 0,3 to 0,6%; one million patients in the USA, two million patients in Europe This may just be the tip of the iceberg High socio-economic cost Cost to the society estimated as approximately $16 billion in the USA, 20 billion in Europe

9 Scientific litterature, previous research approaches CONFERENCE ON MYALGIC ENCEPHALOMYELITIS (ME) FOR HEALTH PERSONNEL, Stavanger, June 12, 2009

10 ME/CFS scientific litterature Over the past 25 years more than 5000 biomedical publications on ME/CFS have been published Early 1990 s -Central role for HHV-6, EBV (Ablashi, Komaroff, Buchwald) - Increased RNase L activity (Suhadolnik et al) Later - Mycoplasma/Chlamydia infections (Nicholson et al) - Bornavirus (Kuratsune et al) - HHV-6A/B and CNS (Peterson et al) - Fragmented RNase L (Suhadolnik et al) - Spectscan abnormalities (Da Costa et al) - Immunological abnormalities (Klimas et al)

11 ME/CFS research in the 21 st century Proteomics Genomics subgrouping patients New infections Small therapeutic intervention studies Ampligen study Until 2008: no attempt to fully explain the pathophysiology of the disorder; lack of integrative approach

12 Research topics in Brussels : immune dysfunctions CONFERENCE ON MYALGIC ENCEPHALOMYELITIS (ME) FOR HEALTH PERSONNEL, Stavanger, June 12, 2009

13 2-5A / interferon pathway dysregulations Infection Food Metals, Chemicals Genetic Background 2-5A PATHWAY 2-5OAS 2-5OAS-like Thyroid hormone resistance FATIGUE Immune System RNase L Cleaved RNase L Channelopathies High Elastase Activity Allergy Chronic Inflammation Low NK Opportunistic infections Viral reactivation PKR ROS ROS Oxidative Stress NO Oxidative Stress Cognitive problems Pain perception Depression Ryanodine receptors Oxidative damage Ion channels CNS Low CRH Decreased response to stimulation Stress HPA axis Muscles

14 Regulation of T-cell immunity TH1 cells Protection against intracellular pathogens (viruses, bacteria) Excess: hypersensitivities IL-12 IFN-γ Naïve T cells IL-4 TH2 cells Protection against extracellular pathogens (parasites, bacteria) Excess: allergies TGF-β + IL-6 TH17 cells Local immunity (mucosa, skin) Protection against fungi, bacteria Excess: autoimmunity, inflammation

15 TH1/TH2 imbalance

16 TH17 pathway TH17 cells are crucial regulators of inflammatory and autoimmune processes - Produce IL-17 cytokines, IL-22, IL-26. Involved in allergic inflammation, asthma, rheumatoid arthritis, multiple sclerosis, intestinal diseases Clinical abnormalities in ME/CFS are consistent with Th17 activation - Th1/Th2 imbalance (Th1 and Th17 are antagonists) - Inflammation - Neurocognitive problems (Th17 cells promote blood-brain barrier disruption and CNS inflammation)

17 Genetic predispositions influence TH17 activation Lower frequency of IL-17F sequence variant (His161Arg) in CFS/ME patients - IL-17F produced by Th17 cells; strong pro-inflammatory effect - His161Arg variant (C/T polymorphism, rs763780) confers protection against the pro-inflammatory effects of the wild-type cytokine His161Arg variant is present in 6% of patients, vs. 31% of matched healthy controls Belgian/Dutch population; similar results in a Norwegian population. Total 107 patients, 64 controls Suggests that Th17 activation contributes to the pathogenesis of the disease

18 Research topics in Brussels : viral infections in the gastro-intestinal tract CONFERENCE ON MYALGIC ENCEPHALOMYELITIS (ME) FOR HEALTH PERSONNEL, Stavanger, June 12, 2009

19 Intestinal dysfunctions in ME/CFS patients ME/CFS patients present numerous intestinal symptoms Nausea Poor appetite Gastric reflux Abdominal pain Abnormal bowel motility Bloating Previous reports of enterovirus infections in the gastro-intestinal tract of ME/CFS patients (Chia et al)

20 Viral infections in the gastrointestinal tract: HHV-6 HHV-6 in stomach and duodenum biopsies 13 to 31% of all biopsies are positive. Similar proportions in controls and patients

21 Viral infections in the gastrointestinal tract: HHV-7 HHV-7 in stomach and duodenum biopsies HHV-7 detected in most biopsies, including those from controls

22 Viral infections in the gastrointestinal tract: EBV EBV in stomach and duodenum biopsies EBV detected in 15 to 31% of all biopsies. No difference CFS/controls

23 Viral infections in the gastrointestinal tract: parvovirus B19 Parvovirus B19 in stomach and duodenum biopsies Higher frequency of Parvovirus B19 in both gastric and duodenal mucosa of patients, compared to controls

24 Viral infections in the gastrointestinal tract: conclusions Herpesviruses and parvovirus B19 are detected at high frequency in the gastro-intestinal mucosa, which appears as a major reservoir for these viruses. Parvovirus B19, like enteroviruses, is present significantly more often in CFS patients Local viral infections and reactivations could be due to impaired mucosal immunity (TH17 activation, TH1 down-regulation, inflammation) The factors leading to impaired intestinal immunity remained to be discovered

25 Norwegian study on severely disabled patients CONFERENCE ON MYALGIC ENCEPHALOMYELITIS (ME) FOR HEALTH PERSONNEL, Stavanger, June 12, 2009

26 Norwegian study: design, parameters tested Norwegian study focused on a group of extremely disabled patients Purpose of the study: investigate clinical dysfunctions in totally bedridden patients (Karnofski score 20-30) compared to moderately ill patients (Karnofski 60-70), contact controls and non-contact controls Parameters tested included immune function parameters, viruses, intestinal dysfunction markers - HHV-6, EBV antibodies: no differences between the groups - Bornavirus: few positive patients, no more than controls - HHV-6, EBV PCR: a few positive patients. Not always correlated with antibody titers

27 LPS levels differ significantly between the groups Plasma LPS is more elevated in patients with low Karnofski score n=22 mean 25,2 n=29 mean 14,4 n=26 mean 6,4 n=16 mean 9,7 High LPS suggests increased intestinal permeability (leaky gut syndrome). Most likely explanation: altered intestinal flora

28 Alterations of intestinal flora in ME patients (aerobes) Enterococcus and Streptococcus species are strongly over-represented in ME patients : Organisms Control ME patients p-value E.coli 1.0 x x 10 7 p=0.98 Enterococcus spp. 5.0 x x 10 7 p<0.001 Streptococcus spp. 8.9 x x 10 7 p<0.001 Henry Butt, University of Melbourne

29 Alterations of intestinal flora in ME patients (anaerobes) Among anaerobic bacteria, Prevotella is the most consistently overgrown bacteria : Organisms Control ME patients p-value Bacteroides spp. 3.2 x x p=0.39 Prevotella spp. 1.0 X x 10 9 p< Bifidobacterium spp. 6.0 x x 10 9 p=0.001 Lactobacillus spp. 2.7 x x 10 8 p=0.002 Henry Butt, University of Melbourne

30 Ratios anaerobes/aerobes and Gm(-)/Gm(+) Gm(-)/Gm(+) ratio are very significantly altered : Organisms Control Patients p value Anaerobes / Aerobes = 0.08 Gm(-) / Gm(+) ratio <0.001 Henry Butt, University of Melbourne

31 Microbiological assay : sample result Patient presents increased Streptococcus, Enterococcus, and Prevotella

32 Bacterial overgrowth correlates with symptom severity Enterococcus spp. counts correlate with symptom expression : Symptoms r and p-values Headache r=.17, p<0.01 Arm pain r=.20, p<0.003 Shoulder pain r=.15, p<0.04 Myalgia r=.20, p<0.003 Palpitations r=.16, p<0.02 Sleep disturbance r=.20, p<0.004 Henry Butt, University of Melbourne

33 Bacterial overgrowth correlates with symptom severity Streptococcus spp. counts correlate with symptom expression : Symptoms r and p-values Post Exertional fatigue r=.15, p<0.03 Photophobia r=.14, p<0.04 Mind going blank r=.17, p<0.01 Cervical gland lymphodynia r=.14 p<0.04 Palpitations r=.15, p<0.03 Dizziness/Faintness r=.14, p<0.05 Henry Butt, University of Melbourne

34 Overgrown bacteria produce lactic acid NMR metabolic profiles of Enterococcus faecalis Lactate Henry Butt, University of Melbourne

35 Increased production of lactic acid (Lactic Acidosis) could contribute to symptoms Lactic acid bacteria counts correlate with symptom expression : Symptoms r, p-values Mental fatigue r=.18, p<0.009 Photophobia r=.18, p<0.008 Urinary frequency r=.16, p<0.03 Urinary urgency r=.14, p<0.04 Palpitations r=.15, p<0.03 Dizziness/Faintness r=.13, p<0.05 Henry Butt, University of Melbourne

36 Another potential toxin produced by bacteria is hydrogen sulfide (H2S) Hydrogen sulfide (H2S) has important physiological functions... H2S is produced by the cells and is an important gaseous signal molecule, involved in regulation of blood pressure, neurotransmission, muscle relaxation and regulation of inflammation...but exogeneous exposure can be extremely toxic In excess, H2S acts as a mitochondrial poison. It can directly inhibit enzymes involved in the cellular production of energy. H2S also interferes with oxygen transport by blocking hemoglobin in the red blood cells. H2S is a potent neurotoxin Enterococcus, Streptococcus, Prevotella are strong H2S producers

37 A marker associated with H2S production can be measured with a simple urine test 1. Collect urine 2. Open tube containing test reagent 3. Add a few drops of urine to the test reagent 4. Mix by shaking gently. Wait for two minutes 5. Observe color changes. Dark color = positive sample Negative or Pre-ME Moderate Strong

38 Heavy metal exposure is another contributing factor to the disease Patients often present intoxication with mercury, nickel or other metals

39 H2S and heavy metals have cumulative effects, causing reduction of ATP production Gut Mold Strept Fungi E N T E R O Gut barrier Other gaseous mediators : NO. CO. ATP Cell E. coli H 2 S H 2 S Mitochondria Bacteria M M M (metals) CH 3 P R P C P R P DX S M S CH3 S CH 3 M S CH3

40 Heavy metals interfere directly with energy production Extracellular + NO. S S O.- H 2 R-S - S Cu ONOO. 2+ S S H S Oxidase Plasmamembrane Q10 Intracellular NADH Krebs cycle ATP Adapted from James Morré 2006 J Inorg Biochem

41 Genetic and environmental factors contribute to aberrant protein conformation P R P C P R P DX Genetic Environmental Acquired Mutation s Heavy Metals P R P DX

42 Abnormal protein conformation assay Aberrant luminescence response indicates abnormal conformation

43 Abnormal conformation can be transmitted from one cell to another P R C Metals P R P DX Cell Cell Cell

44 Conclusions: physiological dysfunctions in ME/CFS, patient evaluation CONFERENCE ON MYALGIC ENCEPHALOMYELITIS (ME) FOR HEALTH PERSONNEL, Stavanger, June 12, 2009

45 Disease severity in ME is associated with different physiological dysfunctions I Pre-ME II Moderate disease III Severe disease Dysfunctions Abnormal faecal test, high H2S Abnormal faecal test, high H2S, exposure to heavy metals Abnormal faecal test, high H2S, exposure to heavy metals that has caused aberrant protein conformation (APD) Symptoms No fatigue, possible gastrointestinal symptoms. Low VO2, slow recovery. Fatigue, gastro-intestinal symptoms Strong fatigue, multiple symptoms May be asymptomatic Treatment Restore the gut: probiotics Restore the gut: probiotics, enterocoated antibiotics. Metal chelation, Zinc supplementation Difficult. Gut restoration, metal chelation. Treatment of associated dysfunctions (opportunistic infections). Treatment of APD is still experimental Increasing immune dysregulations (depressed T and NK cells, Th17 activation, opportunistic infections )

46 Immune alterations resulting from intestinal dysfunction TH1 cells Dysbiosis causes a decrease of CD8+ cells and TH1 immunity: viral reactivations IL-12 IFN-γ Naïve T cells IL-4 TH2 cells TGF-β + IL-6 TH17 cells TH1 downregulation allows increased TH2 and TH17: allergies, inflammation, blood-brain barrier disruption

47 Patient evaluation Urine test for marker associated with H2S production Intestinal microflora evaluation Heavy metals analysis Presence of proteins with abnormal conformation Assays evaluating subsequent immune dysfunctions (immune dysregulations, opportunistic infections...)

48 CONCLUSIONS Gastro-intestinal dysfunctions play a central role in the pathogenesis of ME Dysbiosis detrimental effect mediated by increased production of H2S Immune dysfunctions and opportunistic infections arise as a consequence of pre-existing intestinal problems Once established, infections will contribute to the maintenance/aggravation of the disease

49 Acknowledgements Henry Butt at the Bio21 Institute, University of Melbourne Marian Dix Lemle, Independent Researcher, Washington DC Med Hypotheses Jan;72(1): Epub 2008 Sep 16. Hypothesis: chronic fatigue syndrome is caused by dysregulation of hydrogen sulfide metabolism. Lemle MD.