By Rosamond Vallings
March 19, 2014
The day opened with a very good overview of the work being undertaken at Stanford: Â Jose Montoya; The Stanford ME/CFS initiative; a brief history of collaboration, innovation and discovery in the filed of infection-associated chronic diseases.
He talked of a large team working over 4 years. He described ME/CFS as a real illness affecting many lives.
He presented a case study initially of a patient who had HHV-6 in the blood and cerebrospinal fluid, treated with valganciclovir with a good response. The MRI had shown bright lesions in the right thalamus. Antivirals were again being considered after this patient relapsed later.
He then elaborated on the fact that there are subsets of this illness, and evolution of the illness over time. Stanford got involved as they came upon many patients face-to-face.
The Stanford Initiative is looking at the immune system, genes, neuroradiology, EEGs, cardiology and infectious diseases. He mentioned how some patients are bedridden and have extreme sensitivities. It is likely that there are infections triggering the illness or perpetuating it. Valganciclovir is helpful for HHV6 and EBV. But none of this is necessarily the full answer. Trials did demonstrate the effects of antiviral therapy, which also has an immunomodulatory effect. They are now looking at the effects of methylphenindate as a treatment plus a nutrient formula.
The underlying principles: much time and questions, a multidisciplinary team, clinical and translational research and methodology (double blinded, placebo controlled trials). There needs to be a candid and rigorous approach.
Their clinic has 600 patients currently and a waiting list of 300. They have a multidisciplinary team and have weekly meetings. 3 groups of trials are currently running: drug studies, longitudinal studies and case control studies—e.g., cytokine levels associated with severity. In this one, 13 cytokines are found to have an upward trend leading to many effects, and levels correlate with severity. In addition there are associations with autoimmune disease, and this may be consistent with an auto-immune process going on in ME/CFS. 2 cytokines are particularly higher in women: leptin and resistan. The LASSO method is used. TGFbeta correlates with duration of illness, is decreased and levels correlate with severity. This opens the door for treatment with antiinflammatory agents. Rest, good sleep and meditation are all options to be considered.
Beth Unger: Epidemiology of CFS–what have we learned?
She started by saying that there is often disagreement about terminology and definition, which can be confusing. I.e., Are CFS and ME synonyms or different?
There is consensus that the illness is characterized by severe fatigue unrelieved by rest, and accompanied by additional symptoms, such as post-exertional malaise and cognitive difficulty, etc. There may be other comorbid conditions. The key issue is the vicious circle of sleep, pain and fatigue leading to cognitive difficulties.
The areas of disagreement in the definitions seem to be duration, number of symptoms, exclusion conditions and whether post-exertional malaise is acquired or part of the disease. Most studies are based on the 1994 Fukuda definition and this is widely used. The findings can be extrapolated to other definitions. 80% of patients do have post-exertional malaise. Case definitions are inadequate to explain the actual experience of the illness. Patients and caregivers do however speak eloquently.
Epidemiology looks at demographics, prevalence, significance, prognosis and risk factors.
Prevalence: The highest prevalence is in the 40-50 year old age group. More females than males are affected. It does occur in children. Prevalence may be higher in some racial groups and the socially disadvantaged. Most CFS patients are ill for more than 5 years. 50% seek medical care.
When finding out how common the illness is, it depends where you look and how you ask. A meta-analysis of 14 adult studies showed a different picture with self-report of 3.2% and clinical assessment at 0.76%. Prevalence is likely about 0.31% in the USA, which equates to about 1 million sufferers. In teens the rate is between 0.4% and 2.4%. it is not rare.
Significance: Functional impairment is equivalent to that in MS, HIV, cancer, diabetes and lung disease. There is frequently inability to attend school. There is decreased working memory and motor speed. Various domains of the SF36 generate generally low scores. For fatigue, sleep and pain, the PROMIST scores are worse compared to other illnesses.
Economic burden: In the USA, $9-37billion is lost in productivity, (equivalent to 19% reduction in earnings) and $9-14billion in medical costs.
Barriers to healthcare utilization: Over half the patients had at least one barrier. These included: accessibility, negative illness beliefs, the healthcare system itself.
Prognosis: Presentation of the illness may be sudden or gradual, and symptoms wax and wane. Good clinical management leads to increased wellbeing and functional improvement. The likelihood of recovery decreases with the severity of the illness. Recovery is more likely in children.
Associated factors: Infection, stressors, genetics. Work is usually done using case definitions as there is no biomarker. It is important to identify subgroups.
Future directions include: a multi-site study of CFS/ME and exploring the use of national surveys.
Jarred Younger–Daily fluctuations in cytokines in CFS/ME
This is a novel way of looking at the immune system. i.e—tracking symptom variability comparing good days and bad days and cytokine levels. We need to be able to track something in the blood, and this could be a potential target for new drugs. Cytokine levels may correlate with symptoms. Fluctuating levels may influence symptoms. There are now free programmes/apps to track symptoms over 25 days. Blood is then needed for 25 consecutive days, but with tiny needles and skilled phlebotomists, this need not be too difficult. Classic cytokines and chemokines can be measured.
His team had looked at 3 women with fibromyalgia, and found that leptin levels correlated in all three with symptoms. They then looked at 10 women with CFS/ME, and found that leptin levels correlated with fatigue in 6 of the 10. Comparing with 10 healthy women there was minimal correlation. A network analysis of all cytokines relating to fatigue was done, and leptin was the only one that significantly correlated.
Leptin was three times higher in females than males. It comes from the white fat tissue and is increased in stress and is very "inflammatory."
The microglia are the primary defence in the CNS. Firing leads to a pro-inflammatory state, which makes a person feel ill – this is a normal "sickness response." Microglia can be primed by aging, genetics etc and this can lead to over-expression. The astrocytes take over once the microglia are activated. Leptin crosses the blood-brain barrier and primes the microglia (lowers the threshold). If hit by TNFalpha, leptin increases the vulnerability of the microglia.
He then asked the question "What next?"—leptin antagonists—there are many possibilities, but this is not applicable yet. But cardiac hormones and some antihypertensives do have anti-leptin effects. He noted too that leptin suppresses the appetite. Leptin levels decrease with avoidance of stress.
Modulators of leptin include: naltrexone, minomycin, dextromethorphan, rimfampicin, ceftrixone. A number of natural compounds have the potential too such a tumeric, reservatrol and stinging nettle, but none have been tested.
A biobank is needed, so that more analyses can be done. He noted that leptin can be measured in saliva.
Amit Kaushal—Gene expression findings in CFS/ME
The approach by the Davis Lab was to look at phenotypes and gene expression. 200 patients and 400 healthy controls were assessed. MFI (20 scale) was used with 20 questions. This showed that the phenotypes of the patients were different from the controls. There was much variability in the CFS group—fatigue was far greater than in the controls. Looking at gene expression, whole blood was used looking at RNA activation, microarray overview etc. 47,000 genes can be measured simultaneously in patients versus controls. False positives are possible.
When looking at the sickest patients versus the healthiest of the controls there were more significant genes. There were a large number of genes showing significant different expression between patients and controls. Diseases with systemic inflammation were more highly correlated.
Limitations in the studies are whether there is significance of blood markers. But if there is a signal, the signal should be chased. He concluded that CFS/ME is a heterogeneous disease phenotypically, and there is genomic evidence for a chronic inflammatory state. The inflammation is associated with core intracellular components.
He talked about 3 studies:
1. Small heart syndrome (Japan)—56 cases, 38 controls. There was significant difference between the CFS patients and controls using chest xray and echo, with patients having a smaller heart. However in the CFS group, only those with a low cardiac index were included, but this did not apply to controls.
2. Impaired cardiac function in CFS measured by MRI tagging—12 patients, 10 controls. The cardiac index (equivalent to output) was lower in CFS. Left ventricular volume was down, there were reduced cavity volumes, and reduced stroke volume and cardiac output. This correlated with a markedly reduced blood volume.
3. Evidence of diminished cardiac function. The study involved sedentary and non-sedentary controls and mild and severe CFS patients. 12 lead ECG was used. Cardiac index was down in patients who also had a possibly 15% decreased blood volume.
Problems noted: no data on vascular pathology, no study without some bias, cardiovascular matching is not easy to achieve.
A further phenotyping study was presented, with 82 patients. Exclusion included, obesity, athletes, Ehlers danlos, any cardiac condition and those unable to exercise. Results showed: cardiac remodeling in patients, with smaller cavities (because of different levels of fitness), no clear differences between L and R ventricular function and no signs of early cardiovascular aging or increased risks.
Michael Zeineh—MRI findings in CFS/ME
He is a neuro-radiologist. He had looked at 14 CFS patients and 15 controls. He outlined his 3T imaging protocol, looking at volume, grey/white matter and perfusion. Grey matter in CFS was similar to controls, white matter was lower in CFS than controls, and the thalamic volume was slightly down in CFS compared to controls. He also looked at cortical thickness, which thins in dementia. The cortex was thicker in 5 regions in patients and the differences were more noticeable in younger patients. There are many tracts in the brain, and these are affected by handedness. There was no difference in Arterial Spin Labelling perfusion, but there was increased cortical thickening along the endpoints of both arcuate tracts. In patients there was increased phosphatidic acid in the arcuate and inferior longitudinal fasciculus.
Marcie and Mark Zinn—EEG/LORETA (low-resolution brain electromagnetic tomography) studies suggesting cortical pathology in ME/CFS
They looked at 50 patients and 50 controls, using a standard EEG. Peak frequency is associated with cognitive function. The CFS patients showed reduced PAFs over 58% of the cortex, This was significant, and suggests brain pathology. They then looked at the effects of fatigue, and this predicted the PAFs well. The implications are that there are interruptions in goal-directed behaviour. This leads to mental status changes (cognitive problems) affecting alertness and attention, memory and temporal organisation of behaviour. These findings could help confirm the diagnosis, monitor disease progression and monitor treatment response.
They then determined whether LORETA can be applied to the understanding of cognitive impairment in CFS, and to examine the underlying neurological underpinning of CFS. CFS patients had widespread delta sources mainly in the left frontal lobes. Axial slices showed depth and abnormalities.
The implications mean disruptions in transmission of information. This includes: destabilisation of ascending arousal system mechanisms, inhibition of faster brain rhythms—thus more basic generalised functional processing takes place, deficits in language production and syntax, pathophysiological CNS conditions: grey/white matter lesions etc. There are also lower beta-2 sources in CFS, primary motor deficits, sensory ataxia and pain sensation disturbances. Speech deficits occur as a result of abnormalities around Broca's area. There may be behavioural effects such as apathy. All this is a possible indicator of limbic encephalomyelitis.
The implications are that there is central fatigue and brain fog with no psychiatric comorbidity. In summary there is hypoactivation in CFS and LORETA shows this link.
Anthony Komaroff—Medical care of ME/CFS patients
An overview of management of patients with this illness was presented. Age range is 5 – 65 years. 65% patients are female. It affects all socio-economic groups, but is more common in Afro-Americans and Latinos. 50% patients are "shut-in" or bedridden much of the time. Average duration of illness is 14 years (4-36 year range). Post-exertional malaise (PEM) is characteristic and not seen in any other illness. Cognitive impairment is common. The SF-36 shows low scores in all areas. 10% patients achieve full remission, 23% end up with an alternative diagnosis.
This is not depression, as SSRIs do not fix it. There are abnormalities in the HPA, and neurological and immunological abnormalities are not seen in depression. However with psychological assessment, 50% patients have a diagnosis of depression after onset. Prolactin is often elevated in CFS, and decreased in depression.
Abnormalities found include: neuro-endocrine dysfunction, cognitive deficit, autonomic dysfunction, abnormalities on MRI,Spect and EEG, lactate abnormalities in the CSF, striking differences in immune system. There is evidence of abnormal energy metabolism. Infectious agents implicated include HHV6 in 90-95% patients (the receptor is the complement receptor).
Treatment options discussed:
Final words were that case definitions may encompass several different subsets or other illnesses.
Jose Montoya–Circulating cytokines in ME/CFS patients reveal a novel inflammatory and autoimmune profile
Flu-like symptlms are ongoing, but conventional markers are seldom elevated. There is an associated TH-2 shift. He presented a controlled study of 197 cases and 300 controls. MFI20 and FSS scores were measured to assess severity, followed by statistical analysis. Included was the LASSO technique, and also "random forest". In the results, patients and controls were well matched. The CFS patients almost all had PEM. 26 cytokines were found to decline with age. 4 had differences between males and females: Leptin. IL-1alpha, ENA78 and resistan.
15 cytokines behaved differently in CFS compared to controls. 13 out of the 15 were significant differences, and these were the pro-inflammatory cytokines. Mild cases tend to fall below the controls, severe cases tend to fall above the controls.
Activation of B-cells suggests the possibility of autoimmune disease.
IL-17 is associated with psoriasis, IBD, Arthritis and MS. Leptin and resistan are associated with female sex. Lowered TGF-beta is associated with duration of illness—it is a powerful anti-inflammatory cytokine, whose capacity gets lost. The body thus feels inflamed.
Ian Lipkin–Microbial diagnostics and discovery in ME/CFS
He said they were still able to use the earlier XMRV samples. He explained how one started with a hunt for "possible" microbes and then moved onto the "probable" when one could consider treatment options, followed by the "confirmed" when one looked at drugs and vaccines. He told us how emerging diseases usually came from animal sources.
He explained how micro-array techniques moved onto unbiased sequencing. There are 24 million peptide micro-arrays needed to investigate the vertebrate organism. He discussed as an example Kawasaki Disease, an autoimmune condition in children. Often diseases are due to an immunological response to an environmental trigger.
He then went on to discuss the human microbiome—abnormalities of which can create gastrointestinal symptoms, which in children are sometimes predictors for autism. He is interested in this relation to autism. There may be reduced enzyme and transporter RNA. The organism suterella is increased in autism and there may be an antibiotic cause, and a lack of the gene affecting gastrointestinal metabolism.
He then talked about his involvement with the Chronic Fatigue Initiative, who are doing multiplex assays. He is working closely with Montoya looking at viruses. HHV-6 has been found in the plasma of 4 out of 6 cases. Looking for HHV-6 in PBMCs, 13% were positive in patients and 11% positive in controls. Annellovirus was found in 75% of the samples—this may not be useful, but negative findings are as important as positive.
Looking immunologically at CFS/ME IL-17 was elevated in the first 3 years and then decreased. Lower levels were found in the CFS/ME patients' cerebrospinal fluid. They are doing RNA sequencing looking at biomarkers in 100 cases compared to 100 controls. This equates to 117million reads divided into 3 "libraries". But there is a need to control for library effects, as the "library" construction reflected the results – ie processing may be different.
They are also looking for chemicals produced by bacteria which may have systemic effects. He confirmed that there was zero evidence now for XMRV. Contamination is always a problem and contaminants must be eliminated prior to any analysis.
Jose Montoya closed the symposium remarking that this had been a most successful and exciting day.