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Invest in ME conference
London, June 1st
2012
The conference
was preceded by a 2-day ME/CFS
Clinical Autoimmune Working
Group meeting. I was privileged
to attend this meeting of 20
invited prominent researchers
and clinicians. Research into
ME/CFS was presented and
discussed with a view to ongoing
international collaboration. The
main conference then followed
the next day, and was held in
Birdcage Walk, just behind
Buckingham Palace, providing an
exciting prelude to the Queen’s
Jubilee weekend. Security was
paramount, and the conference
was opened by Dr Ian Gibson
after we had had to clear the
building for a fire alarm!
The keynote
speaker was Professor Don
Staines (Gold Coast,
Australia). He presented
auto-immunity as a plausible
hypothesis in the aetiology of
ME/CFS. He discussed the
research programme being
undertaken at Bond University
over the past 8 years.
He began by
asking the question “Is ME an
autoimmune disorder?” He
described autoimmunity as a
reaction of the body to “self-
antigens” involving B and T
cells. B cells are
antibody-producing and CD20 is a
potential biomarker. T cells
need major histocompatibility (MHC)
recognition. Innate immune
responses may be triggered.
(e.g. NK cells, macrophages
etc). He then discussed the
putative autoimmune targets:
ME/CFS is often associated with
infections such as campylobacter
or conditions such as Guillain
Barré
Syndrome. Multiple Sclerosis
(MS) is associated with Epstein
Barr Virus. Molecular mimicry
may occur (an autoimmune
response to an organism or
antigen similar to endogenous
structures). In Sjogren’s
syndrome and myasthenia gravis
(MG) acetylcholine receptors are
autoimmune tagets (e.g. GPCR).
Vaso-active neuropeptides(VNs) –
related to glucagon, secretin,
insulin – are a super family of
small peptide or protein-like
molecules, and potential
activators of adenylate cyclase
(AC), which converts ATP to
cyclic adenosine monophosphate (cAMP).
VNs of particular interest and
relevance to ME/CFS were
discussed: PACAP, VIP and CGRP.
They are widely distributed in
the CNS. Data does support the
notion of VN dysfunction in
ME/CFS and symptoms do match the
putative targets. VPAC2R
receptors are dysregulated.
There are links to FOXP3 and
cAMP metabolism, and the state
of receptors is crucial for
transmission. cAMP is a very
important neurotransmitter
involved in the transmission of
ATP to AMP. cAMP is a
secondary messenger and has a
key role in cell metabolism. It
acts through CREB and ICER
proteins and these have a role
in CNS neuroplasticity,
involving cognition, memory etc.
Further
discussion then focused on
blood-brain-barrier (BBB) and
blood-spinal-barrier (BSB)
function. The BBB keeps unwanted
substances out of the CNS with
pericytes involved.
Vasodilation
controls the entry of immune
cells. Interleukin-1β
and TNFα
are toxic to BBB and BSB and are
antagonized by cAMP. GPCRs may
be inhibitory or stimulatory.
Autoimmunity can lead to loss of
organ function. PACAP and VIP
are regulatory co-transmitters.
Skeletal muscle and autonomic
transmission maybe implicated.
They also act on the
acetylcholine system. Various
other functions may include:
regulation of cardiac firing; an
anti-apoptosis role in neuronal
cells; insulin control; hypoxia
regulation; glutamate metabolism
Recent
developments in purinergic
signaling also contribute to
understanding of pathomechanisms
involving VNs in relation to
ME/CFS. ATP signals cellular
stress and negatively regulates
AC. ATP may also have
extracellular effects. There are
also roles for VNs in Tregs
(regulatory T cells) and NK
cells. Tregs have an important
contributory role.
Another question
asked was: Are there
abnormalities in mRNA and
microRNA?
Discussion then
followed as to whether symptoms
of ME/CFS relate to
neurotransmitter function,
Purinergic signalling is
involved in neuropathic pain. VN
function is involved in
neurohormonal function,
immunoregulation, and
cardiotropic regulation.
Pathomechanisms indicate
derangements in the VN function.
Abnormalities have been shown on
MRI, showing disorders of
micro-circulation, which are
associated with onset of
illness, loss of CNS function
and illness severity.
In conclusion,
Prof Staines feels that a novel
auto-immune mechanism may be
involved implicating vaso-active
neuropeptides. This hopefully
will eventually lead to
treatments.
Dr Sonya
Marshall-Gradisnik
(Gold Coast, Australia)
presented her work on
immunological dysfunction as
possible biomarkers for ME/CFS.
She pointed out initially that
the pathomechanism is unknown,
there is no diagnostic test but
there is evidence of
immunological dysfunction. NK
cell function is down, Treg
function is implicated in
ME/CFS, and research into B
cells suggests an auto-immune
disorder.
There is
significant reduction in NK cell
function coupled with
significant reduction in
intracellular perforin, which is
responsible for NK cell lysis.
Potential biomarkers include: NK
phenotypes, KIR expression,
decreased CD8 cell lysis
function, decreased gene
expression of lytic proteins of
NK cells, decreased microRNA.
She then
described diagrammatically the
function of the NK cells.
←←←NK cell→→→
↓
↓ ↓
Cytokines Perforin
Granzymes
↓ ↓
↓
→→→→ Lysis of
cell←←←
There is
significantly reduced NK cell
function in ME/CFS, which is
consistent over time. However
the function is similarly
decreased in the moderately
affected group, so severity is
not necessarily significant.
There are 2 types of NK
phenotypes: dim and bright. The
dim seem unaffected in CFS, the
bright very much decreased.
This is consistent over time in
this illness. NK cells are
regulated by Tregs. One KIR
receptor is associated with NK
cell lysis reduction. mRNA gene
expression relates to GZMA lytic
protein which is significantly
decreased in ME/CFS – this is a
potential biomarker.
MicroRNA – there
is a very small non-protein
coding RNA. The mechanism of
post-transcriptional gene
expression is based on
complimentary microRNA.
Differential microRNA expression
is found in NK and CD8 cells.
16 microRNA studies have been
performed and significant
difference was found in 9 in
ME/CFS. MicroRNA regulates Treg
cell function. Treg cells have
been measured. FoxP3 is part of
Treg function and is elevated
over time in ME/CFS, as is CD39
expression. VPACR2 expression in
lymphocytes is also elevated in
ME/CFS.
In Norway, Mella
and Fluge are investigating
anti-CD20 intervention using the
drug Rituximab. Results suggest
that ME/CFS may be an autoimmune
condition.
NK cytotoxic
activity, NK phenotypes and NK
proteins remain as the most
consistent immunological
markers. Emerging areas include:
CD8 lysis, microRNA and Treg
subsets. These may provide
further promise for biomarker
development.
Professor Hugh
Perry
(Southampton, UK) spoke on
neuro-inflammation in chronic
disease. He described how the
symptoms of systemic
inflammation affect behaviour.
This is not maladaptive, but of
survival value. This is an
organized strategy and is what
occurs in the wild, leading to
homeostasis. Examples of effects
on behaviour were given such as
fever, leading to lethargy,
leading to rest. The
inflammatory response “speaks”
to the brain. The key players
are the macrophages in the brain
known as microglia. The
microglia are down-regulated by
various molecules expressed
(inhibitory receptors). In the
diseased brain microglia
proliferate and then are
activated. Perivascular
macrophages communicate with the
microglia, which in turn affect
the neurons.
These
inflammatory changes are seen in
Alzheimer’s disease. Systemic
infection in elderly sufferers
may be acute or chronic.
Worsening symptoms are
associated with increased
microglia and cytokines in the
brain. A longitudinal study was
reported in 300 Alzheimer’s
patients with 6 months follow up
of infective episodes. The more
infections reported the greater
the decline in cognition.
Circulating
cytokines lead to increased
levels of sickness behaviour.
i.e. the microglia have been
primed by infection and the
symptoms of underlying brain
disease worsen. It is possible
microglia are primed by other
events. Priming of microglia
can occur as a result of prior
infection weeks or months
beforehand. It is likely that a
past history of infection can
increase responses in the brain.
He described
experiments where rats were
infected with S.typhi
systemically. There was
increased cytokine activity and
bacteria were cleared in 1-2
weeks. However, the
pro-inflammatory cytokines
continued to have effects on the
brain with switching on of
microglia. All the vascularity
of the brain can be affected and
effects persevere for months.
The environment can have priming
effects on the microglia. For
example animals who were housed
in a “dirty” environment had
greater priming, with larger
inflammatory response.
He said that
ME/CFS seems like an exaggerated
form of systemic inflammation
with a distortion of
homeostasis. Immune to brain
communication may have become
maladaptive. There may have been
a primed innate response in the
CNS, which may be the result of
genetic
predisposition/infection/inflammation/neurodegeneration.
Professor Maria
Fitzgerald
(London, UK) discussed pain in
ME/CFS. She initially gave an
overview of chronic pain, and
described it as a CNS problem.
Pain has a purpose and this may
involve: warning, defence,
escape, learning, protection,
rest, healing etc. Rest is part
of the healing process. Pain can
be maladaptive:
It maybe poorly
related to the actual “injury”
e.g. migraine, fibromyalgia.
It maybe too late
to be a warning e.g. cancer
It maybe
neuropathic e.g. post-surgical,
post-infection
It causes
suffering, depression, anxiety,
lack of mobility etc.
It leads to a
huge economic burden.
She went on to
describe the physiology and
pathology of pain. It is
nociceptive. Persistent pain
may be inflammatory or
neuropathic. Inflammatory pain
is usually tender, aching and
accompanied by stiffness.
Neuropathic pain is usually
stabbing, burning or shock-like.
The nature of
pain is complex:
Sensory component
Motor/autonomic
component
Affective
component
Can alter brain
function (e.g. anxiety)
Affects attention
Individual
differences
Culture, gender
and age all have effects
There are
multiple sites of pain
processing. Pain information is
modified as it travels to the
brain. It can be unpredictable
at every level. The nociceptors
can be primed (e.g. by an
inflammatory agent) leading to
hyper-excitability.
In CFS/ME there
is altered CNS processing.
Fibromyalgia (FM) patients
perceive greater intensity and
greater temporal summation.
Sensations increase in
magnitude, and the CNS winds up
more and more. There is
alteration of endogenous pain
control. FM patients lack
diffuse noxious inhibitory
control. Normally there is
ability to inhibit pain
(endogenous opioids). There is
altered cortical pain processing
in CFS/ME. Numerous areas of
the cortex are involved. There
is activation of the limbic
system (anterior insular-based
ganglia and cingulated cortex).
The CNS is acting very
differently.
Some people may
have a genetic predisposition to
feel more pain.
Single Nucleotide Polymorphisms
(SNPs)
suggest genes related to pain
sensitivity. Plans to
incorporate genotyping are
needed. Early life experiences
may alter pain sensitivity in
adult life – e.g. premature
babies who have had a lot of
pain exposure, may develop an
altered pain threshold. “Injury
“ in the first 10 days of life
may promote effects that last
into adulthood, leading to
vulnerability, particularly if
the same injury occurs, and the
effects can be increasingly
severe. It is not necessary to
have an infection to prime the
microglia, but a “wound” can
lead to microglial activation.
The conclusion
was that genetic determinants
and early life experiences lead
to nociceptor sensitisation,
which is a potential cause of
pain in CFS/ME.
Dr Mario Delgado
(Granada, Spain) discussed his
work with vaso-active
neuropeptides. He said there
are potential therapeutic
opportunities. There is a need
to establish a homeostatic
balance. Cytokines are involved
in the immune balance. The brain
and immune system speak the same
biochemical language. Vasoactive
intestinal peptide (VIP) is
found throughout the body and is
produced in the CNS, the
periphery and non-neural cells.
It has a plethora of functions.
It is involved in the pathway
which activates adenylate
cyclase (AC) which in turn
impacts on ATP and cAMP
metabolism. AC and cAMP signals
are critical for neuronal
survival and other brain
function. VIP receptors are
expressed in immune cells and
have immunomodulatory activity.
He described
therapeutic effects on
experimental inflammation and
auto-immunity, and finds there
is helpful potential in a number
of diseases. VIP protects from
the lethality of endotoxins. It
is neuroprotective in neuro-inflammation
caused by brain trauma, and is
therapeutic in collagen-induced
arthritis. It also has potential
for treating
experimental autoimmune
encephalomyelitis (EAE)
(animal model of MS). In this
condition it inhibits the
inflammatory response and the
Th1 response. It also induces
the emergence of CD4 CD25 Tregs
during EAE. Neuropeptides
induce the generation of
different types of Treg cells.
VIP has been shown to be an
important neuropeptide in immune
tolerance.
He then asked
several questions:
a)
Does a healthy
VIP system make us more healthy?
b)
Is there a role
in ME/CFS? – as many symptoms
relate to the effects of VIP.
c)
Is VIP ready for
the clinical situation? - need
to consider: side effects,
stability, non-oral
administration
d)
What are the
effects on immunosuppression?
Aviptadil (an
analogue of VIP) is marketed for
some conditions such as erectile
dysfunction and the inflammation
associated with sarcoid. VIP
has also had some success in
Guillain Barre Syndrome and
ciguatera poisoning. A clinical
trial is in progress looking at
VIP by inhalation.
Professor James
Baraniuk
(Washington DC, USA) discussed
potential mechanisms of ME/CFS
symptoms. He had designed a
simple questionnaire using the
Fukuda criteria and looked at
severity scores. He had produced
a 3D diagram and had divided his
findings into 4 groups. The
ME/CFS symptoms could be
clustered, and matched the
cerebral spinal fluid
proteomics.
He then went on
to discuss the symptoms seen in
ME/CFS in general.
a) Headaches
He found the
prevalence of migraine headaches
to be 75-80%. 2/3 of these had
no aura, and 1/3 had aura.
There was an accompanying range
of symptoms. There was
improvement with triptans. 67%
of those with migraine were
found to also have
fibromyalgia. There was also a
high prevalence of these
symptoms in Gulf War Illness.
Migraine can cause abnormal
cortical depolarization and
abnormal pain processing, and
accompanying central
desensitization. He hypothesised
that migraine is initiated in
the brainstem.
b) Pain and
tenderness
There was
increased sensitivity to deep
pressure in FM. There was also
increased sensitivity of
proprioceptive and stretch
receptors on nerves innervating
the joint capsules, tendons etc.
There maybe loss of the anti-nociceptive
system, and loss of
norepinephrine release, which
normally regulates responses,
and initiates autonomic
responses. It is as if “the
light is on but no-one is home”,
and the brain is in a default
mode pathway.
He looked at pain
dolorimetry – pressure-induced
thresholds, and did frequency
analyses. Central sensitization
starts in the periphery – there
maybe peripheral sensitisation
such as by hay fever. Spinal
sensitization leads to
hyperalgesia and allodynia.
Microglia are the
key players, and microgliosis
occurs in pain. There is
potential for microglial-neural
biomarkers and useful
therapeutics. Potential
treatments discussed were:
Reservatrol (in red wine),
antipsychotics, tricyclic
antidepressants, anti-oxidants,
endocannabinoids (medical
marijuana).
c) Brain fog –
He discussed the
findings in the grey matter, in
particular the midbrain
reticular substance and
periaqueductal grey matter.
Changes indicated that the
body’s alarm clock is damaged.
There was decrease in the white
matter depending on the duration
of fatigue, and it was found to
shrink by about 1% per year.
d) Sleep
It is likely the
brainstem is involved
e) Effects of
exercise
With exercise,
the brain fMRI shows improvement
in healthy people. He then
described 2 types of people with
CFS: “Increasers” who on day 2
of exercise have to work very
hard to improve their mental
score. And “decreasers”, whose
fMRI shows a lot of activation
on day1, but no task activation
ability on day 2. They are in
default mode only.
The conclusions
in this presentation were: That
fatigue is the result of all
symptoms, that headache is a
result of myalgia and that
general symptoms are due to a
fundamental effect in the
brainstem.
Professor Olav
Mella and Dr
Øystein Fluge
(Bergen, Norway) did a joint
presentation looking at B cell
lymphocyte depletion in
ME/CFS. They reiterated how 3
original lymphoma patients who
coincidentally had ME/CFS had
improved remarkably following
treatment for their lymphoma
with the B cell targeting drug
Rituximab. In these patients
all symptoms relating to their
ME/CFS diminished with the
treatment. B cells may have
something to do with central
mechanisms. The responses
however were delayed for up to
6-12 weeks, despite B cells
being cleared in about 2 weeks.
A further larger
control study was undertaken.
Patients in the study group were
infused with 2 infusions of
Rituximab 2 weeks apart, and the
controls were similarly infused,
but with normal saline. These
patients were then followed
every 2 weeks for 12 months. In
all patients there was a strong
family history of autoimmune
disease. Side effects were
infrequent – in 2 treated
patients, their psoriasis
worsened. 2 patients felt
“unease” and some insomnia.
Several patients had
normalization of a previously
abnormal menstrual cycle. There
was a positive response in 67%
of patients. There was a 13%
response in the placebo group.
Again there was delay in
response and after the effects
wore off the response declined
but was re-instated at the 2nd
infusion. Some patients however
continued to improve but there
was not a consistent pattern.
BAFF (B cell activating factor)
was lower in CFS patients than
controls after treatment. BAFF
is increased in auto-immune
disease. BAFF was again
increased at 3-6 and 8 month
follow ups. This is the
expected normal feedback
mechanism.
Psychological
symptoms did not change
indicating this was therefore
not a psychological illness.
There are ongoing
studies. 1) 26 patients to be
observed for 15 months. This is
a subjective study without
controls. And 2) A severe group
of 6 patients. Plasma exchange
may be given before treatment
with Rituximab. Patients will
be given 2 infusions 2 weeks
apart, with maintenance therapy
at 3-6-10 and 15 months. Follow
up will be for 3 years. Non
responders will be given
etanercept weekly subcutaneously
for a year. They are also
looking at a study on genetic
predisposition in 3 families. As
yet there is no clear candidate
as a plausible target for an
autoimmune process. Over the
past 3 years they have looked
for a specific autoantibody, but
have found none so far.
Something else may be triggering
a pro-inflammatory state.
They reiterated
that patients should not be
treated with Rituximab outside
clinical trials.
The next
presentation was by Professor
Indre Ljungar (Stockholm,
Sweden). Her focus was on a one
year experience of a
standardized team-based
assessment of suspected ME/CFS.
The aim of this ME/CFS project
was to improve diagnosis,
transfer clinical knowledge to
primary care, to establish
rehabilitation methods and to
conduct research. The project
was established in 2010 and used
a team based approach such as
used in other diseases. A
multidisciplinary team was
involved consisting of a doctor,
nurse, psychologist,
physiotherapist, occupational
therapist and social worker.
Diagnosis was based on the
Fukuda and Canadian 2003 case
definitions. Every patient had
a full medical workup, and a
wide range of tests were used.
Included were blood and urine
analysis, polysomnography, 3T
brain MRI. Also included were
2-day activity scores, sleep
questionnaire, WAIS, SF36 etc.
In the past year
101 patient visits were referred
for evaluation, and ME/CFS was
suspected in 55%. Of these 33
fulfilled the criteria for
ME/CFS. Of the others,
diagnoses included psychiatric
illness, sleep disorders,
neuropsychiatric disorders,
other physical illnesses,
fibromyalgia, idiopathic
fatigue etc. The importance of
multi-disciplinary team
assessment, coupled with
thorough medical investigation
was stressed, as symptoms are
very complex and there is
considerable overlap with other
disorders. This approach helps
to create a homogenous group for
potential research. Subjective
symptoms can be tested
objectively and reliable
diagnosis helps in recommending
treatment.
Dr Daniel
Peterson
(Incline Village, Nevada, USA)
gave a clinical research update.
6000 articles have now been
published on ME/CFS. The
greatest challenge is the
disease itself, and there is a
lack of biomarkers. In clinical
research, IT and translational
medicine are becoming more
widely used. Translational
research leads to
multidisciplinary collaboration,
accountability and standards,
shared data and data integration
and common goals drive the
advancement of applied science.
The benefits are: larger
samples, decreased cost, more
controls, increased value of
results, decreased time lines,
and the whole approach is more
manageable for clinicians and
researchers, many of whom may
only work part-time. The
disadvantages are that
technology is forever playing
catch-up and there is almost too
much information generated.
He went on to
describe several new projects:
a)
XMRV/MLV – funded by NIH at 5
sites, using a centralized lab.
Results will be published at end
of June 2012. Samples have been
established, so may be open to
further research.
b)
Chronic Fatigue Initiative
pathogen discovery project to
establish a biobank. There are
40 patients and 40 healthy
controls at 5 sites. Samples of
blood, saliva, urine, faeces and
tears will be taken. This will
help to establish subsets, which
is particularly important for
pathogen discovery. A
centralized biobank will be
established and samples kept at
minus 80̊C.
c)
Collaborative research using
cerebro-spinal fluid. The goal
is to look for aberrations,
pathogens and markers. 30 cases
are being investigated,
evaluating cytokines and
microRNA in the spinal fluid
d)
Simmaron/Bond – molecular and
cellular investigation to
identify NK function.
e)
CFIDS funded research projects –
have established the Research
Institute without Walls for
translational research, and are
funding 5 studies:
1)
Brain imaging looking at blood
markers after exertion.
2)
Cognitive improvement looking at
treatment of unrefreshing sleep
and effectiveness of drugs
3)
Epigenetic markers
–(heritable
changes in
gene expression)
4)
Brain fog,
orthostatic challenges and
therapeutic approaches.
5)
Autonomic
dysfunction looking at
neuromuscular strain/central
sensitization.
f)
CASA (collection,
aggregation, storage and
analysis) – a collaborative
effort between the NIH, CDC and
clinicians and researchers
comparing studies of ME/CFS.
Using many different
questionnaires is not helpful,
and a consensus document is
needed using standardized
questionnaires. Results are
otherwise divergent and often
not useful. The goals therefore
are to establish research
standards and determine
appropriate tools.
g)
The Open Medicine
Institute headed by Dr Andreas
Kojelnik.
Dr Andreas
Kojelnik
(California, USA) is Medical
Director of the Open Medicine
Institute (OMI) – a
community-based research clinic
focused on chronic infectious
diseases, neuro-immune disease
and immunology. He feels there
is much optimism now in that
treatments are beginning to
emerge, mainstream science is
getting interested and
technologies are advancing our
understanding. Disease
acceptance in 2012 is far better
than in 1992, and he pointed out
that many other diseases have
been through a similar history,
with understanding evolving
slowly. We are in a different
era now, with genetic profiling
becoming useful, and accurate in
diagnosis and treatment. In
ME/CFS there is a syndromic
research conundrum. There is a
lot of overlap, definitions are
not mature, there is scarcity of
biomarkers, treatments are not
standardized and outcome data is
limited.
He described how
the OMI works by creating a
network between biotechnology,
informantics, social networking
and biosampling all linking into
clinical medicine and research.
There is need for convergence
of these disciplines. A large
network gains: longitudinal
controls, plenty of samples, a
lot of pilot treatments, control
over protocols and standards,
control over lab measurements
and standards and options to use
the best of the best.
He went on to
describe research progress in
the past year:
a)
Positive studies with Rituximab
b)
XMRV studies “debunked”
c)
CDC funding clinical networks
d)
Ampligen study published
e)
Other molecular studies showing
progress: e.g. spinal fluid in
ME/CFS vs Lyme disease, blood
findings in depression vs
ME/CFS/FM
He then outlined
the work being undertaken at the
OMI:
Diagnostic
studies
a)
Viral flora –. sequencing and
quantitation
b)
Antibody/antigen array
c)
Cytokine arrays
d)
Deep sequencing
Treatment
studies:
a)
Valganciclovir and other
antivirals (NB long delays in
response)
b)
Anti-inflammatories
c)
Rituximab
d)
Rifaxamin (antibiotic) etc
Aetiology studies
a)
Immunological studies
b)
Infections: bacterial, viral
c)
Metabolic derangements (VO2 max,
mitochondria etc)
d)
Environmental factors (heavy
metals, diet etc)
Today, much
collaboration is occurring
internationally between
academia, industry and
government. The OMI is very
involved and now has a biobank
of 10,000 patients.
This conference
was organized by Invest in ME,
and I must thank them for
producing a wonderful event.
Thanks must also go to the
Alison Hunter Memorial
Foundation and ANZMES for
enabling me to attend.
Rosamund Vallings
MNZM, MBBS
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