Bond University’s Population Health and Neuroimmunology Unit (PHANU), with the support of the Alison Hunter Memorial Foundation and the Queensland Government’s Office of Health and Medical Research invited a number of national and international specialist scientists working in the field of ME / CFS and neuroscience to take part in a specialised Symposium dedicated to neuroscience developments and their application to ME / CFS.
The Symposium was designed to bring together top scientists from around the world to focus on the current state of research into ME / CFS and help set a focus for immunological and neurological research in the future.
Sonya Marshall-Gradisnik, Associate Professor of Biochemistry at Bond University said,
“This is the first purposefully designed international conference exploring developments in neuroscience and immunology from researchers involved in ME / CFS research as well as experts who may previously have known very little about ME / CFS, but whose incisive minds and research skills will be applied to unravelling this perplexing condition.”
Nancy Klimas Hugh Perry Mary Ann Fletcher Dominic O’Donovan Olga Sukocheva Dan Peterson
Ekua Brenu Kenny de Meirlier Richard Kwiatek Barrie Marmion Anne Boullerne Warren Tate
Douglas Feinstein Doina Ganea Monica Carson Donald Staines
The first paper was by
Nancy Klimas (Miami,
USA), and she presented a systems biology approach to ME/CFS.
She described CFS is a
disorder of homeostatic imbalance.
She briefly outlined her 25 year history of involvement with this
illness, when initially she worked on the theory of a chronic immune
activation syndrome, with an immunological focus.
It was next recognised as a neuro-inflammatory disorder, and now
genomics have become involved.
She listed and described some of her current research work.
One study involved an
exercise challenge to induce relapse, looking at the gene expression and
immune changes before, immediately after and 4 hours later.
Three matched groups
were studied: Gulf War illness, CFS and controls.
The exercise challenge
was 8 minutes on an exercycle with measurement of VO2 max.
The gene expression showed significant differences in those with GWI
and CFS. (By case
definition GWI and CFS meet the same criteria).
Immunological pathways
were similarly affected – these were mainly inflammatory, and the immune
cascade led to many symptoms 4 hours later.
Symptoms involved the
endocrine, immune, autonomic and neurological systems. The genes regulating
NK function which included abnormal perforin and granzyme levels were
affected.
Dr Klimas went on to
describes Broderick’s three basic elements of analysis of immune signals,
and related this
to the states after the 8 minute
challenge:
1. Those that looked
different
2. Those that hang out with a different crowd
3. Those that behave
differently (altered response dynamics)
In this study there
was persistent inflammation, a surge in immune interaction and an IL-1
“splash” effect. There was a
huge cascade effect in 8 minutes and persisting 4 hours later.
Homeostasis is “messed
up” and needs to remodel.
There is a need to
focus on autonomic and immune therapies which do interface with each other.
This study confirms
that graded exercise is not good for those with CFS, and patients must stop
exercise well short of the aerobic threshold.
Breaks between
exercise need to be twice as long as the duration of the exercise.
2. Hugh
Perry
(Southampton, UK)
discussed the adaptive and maladaptive components of what he describes as
“sickness behaviour”.
He then focussed on
the language of “sickness” in relation to the way the systems behave during
inflammation, for example “feeling ill” with pain and fever, describing
sickness behaviour as an organised strategy which is not ‘bad.’
Infection leads to an
inflammatory response with release of cytokines, which then communicate with
the brain and cause symptoms such as malaise, fever and depression.
Systemic inflammation activates selective brain regions, with
different challenges activating different regions.
This mechanism works
through the macrophages in the brain via the blood-brain-barrier.
Endothelial cells communicate with the macrophages via the microglia.
This is an important part of homeostasis, and is usually transient.
He then went on to
talk about chronic neurological disease when microglia increase in number
and activation and become “primed”.
Exaggerated sickness
behaviour then occurs in those with chronic brain disease, in response to
infection. The microglia
release cytokines very readily if already primed.
A maladaptive pathway develops.
One study involved the
follow up of 300 Alzheimer’s disease (AD) patients 2 monthly for 6 months.
Those who had an infection had a more rapid mental decline, while those who
had suffered no infection showed no change.
Other “behaviours”
also changed greatly as a result of infection.
He described obesity, smoking, age and grey hair as all contributing
to earlier AD as all these have inflammatory effects.
Dr Perry concluded by
saying that systemic infections lead to distortion and maladaption exhibited
by sickness behaviour, because of the primed microglia.
This in turn leads to
accelerated progression of brain disease.
He said that a
vaccination can be used as a challenge to demonstrate changes, and
functional MRI has more use at detecting these changes.
3. Mary
Ann Fletcher
(Miami, Florida)
presented her work on biomarkers for CFS.
The goal in CFS research has been to find a biomarker or combination
of biomarkers. This will
enhance the ability to diagnose and demonstrate severity of the illness,
define subsets and help to manage trials.
Natural killer (NK)
cells were studied initially looking at function and the diminution of
perforin and granzyme. 176 CFS
patients showed significantly lower function in NK cells compared to
controls.
Dr Fletcher then went
on to describe how neuropeptide-Y (NPY) is involved in the stress reaction
with increase in norepinephrine and NPY from the sympathetic nerve endings.
In a controlled study,
NPY was considerably higher in CFS compared to controls.
Use of receiver
operating curve (ROC) analysis was described, and this showed discrimination
between CFS patients and controls.
Using ROC, NPY was
found to be 80% sensitive in CFS, (which is better than the PSA test we use
to help diagnose cancer of the prostate).
NPY also correlates
with markers of disease severity. Other potential biomarkers using this
technique included 10 of 16 cytokines measured, NK cell cell function and
dipepdyl peptidase/CD26 which is indicative of immune activation.
This is all part of a
complex integrated system.
In future exercise
challenge will be included in testing this paradigm, and computer analysis
will be developed to stimulate research in further clinical trials.
These abnormalities
may have applications in other diseases.
4. Dominic O’Donovan, (Cambridge, UK) a neuropathologist presented the results of autopsy on four patients who had a specialist diagnosis of CFS:
Differential diagnosis
here was discussed and would have included AIDs, Sjorgren’s syndrome,
varicella zoster and paraneoplastic disease.
These results have
raised the possibility that some cases of CFS may have sensory or autonomic
ganglionitis.
A specific brain and
tissue bank in the UK is proposed.
5. Olga
Sukocheva
(Adelaide, Australia)
presented the immunohistochemical and microbiological post mortem findings
in a 20 year old patient with fatal idiopathic encephalopathy.
This patient had been
diagnosed with CFS following a severe encephalitic like illness when aged
10.
There was evidence of
inflammatory damage with suppression of microglial cells.
Down regulation of ankyrin B was detected in the white matter of the
hippocampus.
There was no
significant difference in ankyrin G.
Tests for Coxiella
burnetii and Legionella were instituted.
C.burnetii antigens were present in astrocytes, and in the microglial
cells in the grey matter of the hippocampus.
C.burnetii antigen was
also found in spleen and liver macrophages,lymphoid tissue, bone marrow,
lung and heart tissues.
Legionella antigen was not found.
6. Dan
Peterson
(Nevada,USA) started
his talk with a brief overview of the incidence and effects of CFS in the
USA.
He then went on to
describe research problems, such as the varied definition, heterogeneity of
patients, lack of biomarkers, patient self-selection, researcher bias and
lack of funding.
Dr Peterson described
a number of “scientific journeys” undertaken in CFS research, and stressed
the importance of the bringing together of the patient, biotechnology,
database informantics, genomics and clinical medical guidelines.
Diseases can now be defined from a molecular perspective. Networking and collaboration are keys to successful research. There needs to be large-scale clinical data gathering, with international bio specimen collection.
He then went on to
discuss the importance of looking at viral infections in CFS.
Leukotropic herpes
viruses particularly HHV6, HCMV and EBV are among a number of major
candidates in CFS.
Dr Peterson reported
on large studies in which active HHV6 was detected in 28%, HCMV in 29% and
EBV in 51%. 10% were
co-infected.
Active EBV infection
significantly correlates with the presence of auto-antibodies, with
antibodies directed at thyroid peroxidase and parietal cells.
Up to 30% of patients may respond to antiviral medication.
7. Ekua
Brenu
(Queensland,
Australia) had looked at innate and adaptive immunity in CFS. It was
postulated that her study could assist in developing biomarkers.
The study involved 253 patients and 100 controls.
Studies were undertaken at zero and 6 months. Cytotoxic activity of
NK cells and CD8+T cells was significantly reduced.
Perforin and granzyme
activity was reduced.
When looking at NK
cell phenotypes, CD56 bright cells were significantly diminished.
Cytokine secretion
from CD4+T cells showed significant elevation of IL-10, IFN-γ and TNF-α.
FOXP3 expression was also heightened in the CFS group.
Vaso-active intestinal peptide (VIP) receptors were also investigated
and found to be significantly elevated.
8. Kenny
de Meirlier
(Brussels, Belgium):
Because chronic activation of the immune system is present in progressive
HIV and is a better predictor of disease outcome than viral load, it is
important to test the hypothesis that a similar pattern may be observed in
XMRV positive CFS patients.
16 XMRV positive
patients (using culture assay) had a large number of tests performed.
These patients were found to have reduced lymphocyte numbers and
CD-57+lymphocytes reduced, as observed in HIV.
There was evidence of
an activated innate immune system (increased elastase activity and C4a).
sCD14 was significantly higher than expected, and this correlated with
plasma lipopolysaccharide (LPS) a pro inflammatory component of the
gram-negative bacterial envelope.
Low stool IgA
indicated dysfunctional mucosa-associated lymphomal tissue in XMRV positive
patients. Serum IL-8, IL-10, MCP-1 and MIP-1β are increased and might
constitute a biological signature for viral infection.
This all provides
supportive evidence for microbial translocation being part of the pathology
of XMRV +ve patients.
He described a
Norwegian study of severely disabled CFS patients in which the plasma LPS
was elevated in those with a low Karnofsky score.
This suggests a leaky
gut syndrome. Stool analysis in
CFS patients has indicated overgrowth of enterococci, streptococci and fungi
with diminished E.Coli count.
This can lead to overproduction of hydrogen sulphide
which is toxic to
mitochondria and affects ATP.
9. Richard
Kwiatek
(Adelaide, Australia)
is a rheumatologist with a particular interest in neuro-imaging. MRI was
performed to look for brainstem dysfunction in CFS.
Whole-brain optimised voxel-based volumetry and novel quantification
of T1-weighted and T-2 weighted signal levels in structural MRI were used.
Voxels build a 3-D map of the brain.
In the CFS patients
seated pulse pressure was reduced, and seated heart rate and asleep heart
rate were increased, compared to controls. This was then correlated with
brain change, other symptoms and fatigue.
Prefrontal white
matter volume reduced with increasing sleeping heart rate in CFS with the
opposite in controls. Midbrain
white matter volume reduced with increasing fatigue.
There was a strong
correlation between total brainstem grey matter volume and seated pulse
pressure in the CFS patients.
Brainstem grey matter
changes suggest a failure of cere brovascular auto-regulation, potentially
mediated by astrocytes.
Astrocyte dysfunction may therefore be central to CFS pathogenesis.
There seems to be
disrupted autonomic nervous system homeostasis, but he does not feel it is
reduced blood volume that will be causing this.
10. Barrie Marmion
(Adelaide,
Australia) has studied Q-fever and its aftermath for many years. There were
11 suffering from post Q-fever fatigue syndrome out of 39 who had had the
acute illness in one study cited.
The C.burnetii antigen
persists, and causes immune modulation with gene expression and symptoms.
Usually it is continuous from the initial onset, but episodic
relapses may occur due to re-infection or inadvertent Q-fever vaccination.
IL-6 is elevated and IL-2 is down.
The symptoms fit the criteria for a diagnosis of CFS.
Three Q-fever groups
were studied and there were differences in the frequency of carriage of
HLA-DR B1*11 and of IFN-γ. 35%
were positive in the post-Q-fever syndrome group, and the levels were low in
the controls and Q-fever recovered group and the Q-fever endocarditis group.
These differences
support the concept of different immune states in chronic Q fever,
determined by genetic variations in host immune responses, rather than by
the properties of C.burnetii.
11. Anne Boullerne
(Illinois,
USA) discussed the issue of chronic fatigue in relation to CFS and MS, and
described MS as a characteristic auto-immune disorder, and outlined the
differences in incidence, symptoms, duration of illness etc.
She emphasised that
while MS is a neuro-immune disease, CFS is an acquired severe complex system
dysfunction. In MS there is
oligoclonal IgG in the CSF in 95% of cases, and
brain lesions
with
T and B cells
are seen on MRI.
She asks the question “Is gliosis present in CFS?”
In CFS MRI
abnormalities maybe found such as small punctate subcortical white matter
intensities in the frontal lobes, small ventricular volume, slow blood flow
and some atrophy. She had
looked at functional MRI in relation to control imagery and visual imagery.
Both were found to be
slower in CFS compared to controls.
Changes associated with finger tapping and auditory monitoring
correlated with subjective fatigue and brain response during challenge
involving memory.
Using
M.R.Spectroscopy, there was an increase in choline in the basal ganglia, no
significant difference in glutathione, and ventricular lactate was elevated.
There was no alteration in levels of GABA and glutamate.
In a rat model for Gulf War Syndrome, using pyridostigmine, there was no gliosis and no increased permeability of the blood brain barrier. A possible auto-immunity including vasoactive neuropeptides is hypothesised.
12. Warren Tate
(Dunedin,
NZ) and his team have just initiated a study to develop tools that can
accurately detect molecular changes within cells in response to
double-stranded RNA (dsRNA) relevant to CFS.
He explained how
recent XMRV findings had stimulated research and a need for a bank of
genetic material. Biomarkers
need to be established as well as less specific markers to reflect changes
in global homeostasis. There needs to be targeting of a vulnerable point in
the biology of XMRV viral RNA that determines the ratio of its structural
and enzyme proteins.
He went on to describe
types of biomarkers:
Dr Tate explained the
RNaseL activation pathway.
RNaseL cleavage may be specific to CFS. He is currently studying the ratio
of the RNaseL terminal fragment to uncleaved protein, and he will also be
looking at abnormal PKR activation.
This is cleaved by
caspase to form the 37D fragment. This undergoes phosphorylation which can
be measured – the protein-synthesis factor e1F2α. These two phosphorylation
events will be detected by specific antibodies against the phosphopeptides
of the two proteins.
13. Douglas Feinstein
(Illinois,
Chicago) presented study of noradrenergic treatments for neuro-degenerative
diseases.
Glial cells are
activated producing neurotoxins, which induce neuronal damage and leukocyte
infiltration into the CNS.
Noradrenaline
regulates glial inflammatory responses, exerts neuroprotective effects and
helps maintain the integrity of the blood brain barrier (BBB).
Dysregulation of noradrenaline signalling could exacerbate disease.
The supposed reductions of noradrenaline increase inflammatory responses,
the amyloid burden and neurotropic factors.
Noradrenaline is
mainly produced in the locus coeruleus (LC). This part of the brain is
damaged in Alzheimer’s and Parkinsonism.
LC loss correlates
with plaque and tangle numbers.
The question was asked “does increasing noradrenaline in the CNS improve
things?”
The drug Droxidopa is
a precursor of noradrenaline. This drug is in phase 3 trials for neurogenic
orthostatic hypotension.
In mice the drug leads
to improvement in plaques and learning.
This drug used in MS and
experimental auto-immune encephalmyelitis (EAE) showed stabilisation
compared to controls. This
trial indicates that the LC is significantly damaged in MS and EAE.
Noradrenaline directed
therapies need to be considered if there is perhaps also LC disturbance in
CFS.
14. Doina Ganea
(Philadelphia, USA) spoke about Vasoactive Intestinal Peptide (VIP) – an
endogenous and exogenous immunomodlator.
VIP down regulates the
innate immune response by inhibiting the release of pro-inflammatory
cytokines, chemokines and nitric oxide by activated macrophages, microglia
and dendritic cells.
It also affects the
adaptive immune response by reducing the co-stimulatory capacity of
antigen-presenting cells, and by inducing Th2 type responses.
She had looked at several diseases, such as collagen-induced
arthritis and autoimmune encephalmyelitis.
She had used dendritic cells generated in the presence of VIP/PACAP
as immunomodulatory agents, with positive results.
15. Monica Carson
(California, USA) had studied the CNS expression of the classic chemokine
CCL21. This is a predisposing factor for auto-immunity due to the
proliferation induced pre-activation.
It thus contributes to
chronic inflammatory disease and auto-immunity.
Experimental work was
done using mice. Resulting data
indicated that CCL21 expression within the CNS has the potential to
contribute to T-cell mediated CNS pathology.
This could occur via
homeostatic priming of CD4+T cell lymphocytes outside the CNS, and CD4+T
cell migration into parenchymal site after infection with organisms such as
toxoplasma.
16. Donald Staines
(Gold
Coast, Australia) rounded off the formal papers with a presentation
looking at novel treatments in CFS.
He considered whether
auto-immunity affecting vaso-active neuropeptides suggest a pathomechanism.
ME/CFS may be associated with auto-immunity affecting the function of
vaso-active neuropeptides, such as VIP and PACAP (pituitary adenylate
cyclase activating peptide).
Upsets in adenylate
cyclase (AC) signalling and cAMP functioning possibly involving ATP toxicity
may be a feature of VN auto-immunity.
Purinergic receptors such as ATP negatively regulate AC.
He outlined some basic biochemical principles to clarify things; AC
amplifies incoming intracellular signals; PACAP is an acetylcholine
co-transmitter; AC is involved in long term potentiation and enhanced
maintenance of neuronal activity.
VIP/PACAP synergism is involved with potentiation of cardiac firing,
anti-apoptosis function, cAMP and insulin control, hypoxia regulation and
glutamate metabolism.
Purinergic signalling is involved in centrally mediated pain (neuropathic
pain).
He then went on to
describe some likely treatment possibilities based on these principles.
These included purigenic signalling modulators, VIP/PACAP
mimics/analogues, phosphodiesterase inhibitors: eg Rolipram (toxic),
Ibudilast, Roflumilast; B cell depletors (Rituximab); chondroitinase; VIP
liposomes and lentivirus agents.
Some of these could be considered for clinical trials.
The second day of the
symposium was involved in general discussion with various panels looking at
clinical matters, case definition, guidelines and research collaboration.
Possible name change
was also discussed, and there
was plenty of open discussion, being a small group meant an interactive
forum with everyone participating.
Some of the salient
points discussed were:
Name change:
most people acknowledged that patients do not find the name CFS describes
the severity of the illness – tends to trivialise it. It was agreed that the
name ME was more appropriate in many ways, although still not entirely
accurate for this illness.
There was some
discussion as to whether gut symptoms and possible auto-immune activity
could be incorporated.
Case Definition:
The Fukuda definition is still useful for research and one must bear
in mind that many previous studies have used this definition so it should
not be entirely abandoned, although all agreed that the Canadian consensus
definition is more suitable for clinical diagnosis, and should generally be
adopted.
It is hoped that this definition
will be adopted internationally and renamed accordingly.
All agreed that the
CDC empirical definition should not be used.
The issue brought up
earlier at this symposium of “sickness behaviour” as terminology was thought
to be a backward step, and would be unpopular with patients, although Hugh
Perry explained his reasoning very clearly.
Diagnosis:
The importance of biomarkers was reiterated. These need to be user friendly
and readily available.
There should be
opportunity to sub-group according to type of onset, symptoms and gene
expression. Clinicians new to this illness need to be aware of the range of
long-term diagnoses that may emerge in those with CFS, so that regular
ongoing surveillance is important.
Uniform assessment
tools should be encouraged, although it is acknowledged that not all types
of testing will be available everywhere.
Management/guidelines:
Guidelines need to be
unified, and there should be collaboration among those working on
guidelines.
Nancy Klimas stressed
that financial assistance should be available for a face to face meeting
among experts to work on this.
There
was some discussion about the importance of off-label prescribing, as many
clinicians feel uncomfortable if they do not stick to evidence based
medicine.
A recommendation
should go out in support of being able to use medication in this illness,
where there is some useful research backup, even if not formally trialled,
so that practitioners do not need to fear litigation.
A longitudinal
“n of one” trial of a treatment approach on one patient should be
deemed useful, and clinicians should be encouraged to do this and write up
their results.
Clinical overview:
Five clinicians presented their views on management, and there was much
discussion contributed from those on the floor also.
Mieke van Driel
(Queensland, Australia) presented an overview of drugs used in CFS. Few
trials have been done, and those that have showed little benefit.
She recommended that
we should let patients guide the research agenda by teaching us what works
for them.
Don Lewis (Melbourne,
Australia) discussed the importance of food intolerances, and emphasised
that although gut symptoms maybe prominent, they may not always occur.
A strong family history of intolerances is relevant.
He firmly believes
that intestinal dysbiosis occurs in almost all his patients and the hydrogen
sulphide test was positive in 85% of patients.
IgG antibodies were found to many different foods. He now proposes
formal laboratory based clinical trials.
Bill Cassimatis
(Queensland, Australia) has a number of CFS patients in his general practice
and he outlined his general approach. He mentioned that a number of women
with this illness seemed to be worse cyclically, confirming that in some
women, hormones are involved.
This was discussed
further by Rosamund Vallings (Auckland, New Zealand) who uses oestrogen and
progesterone often in women with CFS with cyclical or post menopausal
symptoms.
Nicole Phillips
(Melbourne, Australia) who is a psychiatrist pointed out that some women can
become depressed on Depo-Provera.
Norman Hohl (Southport, Australia) is relatively new to dealing with this illness, but as a travel medicine consultant and qualifications in infectious diseases, he has a strong interest in preventative strategies.
Research directions: All agreed that this symposium will lead to collaboration internationally.
International concurrent trials are needed, and more funding is essential. Larger worldwide studies are likely to increase funding availability.
Collection of observational data can be of value.
The idea of establishing a CFS registry was considered a valuable approach although this could be often difficult and time consuming for medical practitioners. Using internet self report will not necessarily generate patients fitting diagnostic criteria.
Diagnosis needs to be made with face to face encounter by physicians familiar with the illness. More medical education is thus a very important issue to be addressed.
Immediate plan: A formal press statement was produced for distribution after the symposium outlining the salient points raised.
A list of future directions was also formulated. Some further e-mail discussion and collaboration between the scientists and clinicians is envisaged, and this was a very positive outcome from this symposium.
Many of these people were new to CFS and had never met before, and it seems a whole new set of directions for future research will ensue.
Those who had presented papers were encouraged to make the full paper available for the website which will be set up and meanwhile the abstracts will be available.
Christine Hunter and her AHMF team were formally thanked, together with the team from Bond University. Without all the dedication and hard work by all of these people, this symposium would never have been possible, and everyone agreed it was an enormous success.
The event had been ably chaired by Professor Ken Donald and Professor Mel Miller.
I would like to thank the Alison Hunter Memorial Foundation and ANZMES for enabling me to attend this symposium.
Rosamund Vallings