Immunological findings - overview

ME/CFS

References	Immunological findings
Charakterisierung des phänotypischen und funktionellen Immunstatus bei Patienten mit Chronischem Erschöpfungssyndrom	Examined CFS patients: 11% autoimmune thyroiditis 31% immunoglobulin deficiency, including: ·         5%   IgA deficiency ·         6%   IgG main group deficiency ·         10% selective IgG3 deficiency ·         10% selective IgG4 deficiency ·         8%   elevated IgM 32% T-cell-activation at an increased expression of activation markers CD11a, CD28 og CD57 på CD8 + - T-lymphocytes. 5% had an elevation in CD11a and a decrease in CD28 at CD8 + T-lymphocytes. 33% had elevated CD57 + T-cell-activity CFS patients could be divided into 4 groups: ·         high IL-2 ·         high IL-5 ·         decreased cytokine respons and predominantly T-cell activation and lymphopenia ·         26% no annormal cytokine production 22% had EBNA IgG deficiency 15% had leukopenia 25% had lymphopenia 6%   had low hemoglobin 25% had elevated MCHC niveau
Natural killer cells in patients with severe chronic fatigue syndrome	Severely affected CFS patients characterized by significant decreases in NK lysis and increases in KIR3DL1, IL4, TNF-α, and IFN-γ
Screening NK-, B- and T-cell phenotype and function in patients suffering from Chronic Fatigue Syndrome	·         Increased levels of T regulatory cells (CD25+/FOXP3+) CD4 T cells. ·         CD8 T cells showed significantly lower activation and frequency of effector memory cells. ·         NK cells displayed higher expression of NKp46 and CD69 but lower expression of CD25 in all NK subsets defined. ·         Overall, T cell and NK cell features clearly clustered CFS individuals.
Immunological abnormalities as potential biomarkers in Chronic Fatigue Syndrome/Myalgic Encephalomyelitis	Impaired ·         cytotoxic activity of Natural Killer Cells ·         cytotoxic activity of af CD8+T celler  ·         number of CD56bright NK cells Upregulation of IL-10 IFN- γ TNF-α CD4+ CD25+  T-cells FoxP3 expression VPACR2 expression
Longitudinal investigation of natural killer cells and cytokines in chronic fatigue syndrome/myalgic encephalomyelitis	baseline  = T1,     6 months = T2,      12 months = T3 ·         NK cytotoxic activity was significantly decreased at T1, T2 and T3. ·         Significantly lower numbers of CD56brightCD16- NK cells at both T1 and T2. ·         Cytokine secretion revealed significant increases in IL-10, IFN-γ and TNF-α at T1. ·         Overall cytotoxic activity significantly decreased at T3 compared to T1 and T2. ·         CD56brightCD16- NK cells were much lower at T2 compared to T1 and T3.
Altered functional B-cell subset populations in patients with chronic fatigue syndrome compared to Healthy Controls	CFS patients had: ·         greater numbers of naive B cells as a percentage of lymphocytes: 6·3 versus 3·9% in HC (P = 0·034) ·         greater numbers of naive B cells as a percentage of B cells: 65 versus 47% in controls (P = 0·003) ·         greater numbers of transitional B cells: 1·8 versus 0·8% in controls (P = 0·025) ·         reduced numbers of plasmablasts: 0·5 versus 0·9% in controls (P = 0·013)
Increased IgA responses to the LPS of commensal bacteria is associated with inflammation and activation of cell-mediated immunity in chronic fatigue syndrome	·         Serum IL-1, TNFα, neopterin and elastase are significantly higher in patients with ME/CFS than in Chronic Fatigue  patients. ·         There are significant and positive associations between the IgA responses to LPS and serum IL-1, TNFα, neopterin and elastase. ·         Patients with an abnormally high IgA response show increased serum IL-1, TNFα and neopterin levels, and higher ratings on irritable bowel syndrome (IBS) than subjects with a normal IgA response. ·         Serum IL-1, TNFα and neopterin are significantly related to fatigue, a flu-like malaise, autonomic symptoms, neurocognitive disorders, sadness and irritability.
Cytotoxic lymphocyte microRNAs as prospective biomarkers for Chronic Fatigue Syndrome/Myalgic Encephalomyelitis	There was a significant reduction in the expression levels of miR-21, in both the NK and CD8(+)T cells in the CFS/ME sufferers. Additionally, the expression of miR-17-5p, miR-10a, miR-103, miR-152, miR-146a, miR-106, miR-223 and miR-191 was significantly decreased in NK cells of CFS/ME patients in comparison to the non-fatigued controls
Increased nuclear factor-κB and loss of p53 are key mechanisms in Myalgic Encephalomyelitis/chronic fatigue syndrome (ME/CFS)	Future research should examine p53 signaling in ME/CFS: ·         Inactivation of p53 impairs aerobic mitochondrial functions and causes greater dependence on anaerobic glycolysis, elevates lactate levels, reduces mitochondrial density in skeletal muscle and reduces endurance during physical exercise. ·         Lowered p53 and increased NF-κB are associated with elevated reactive oxygen species. ·         Increased NF-κB induces the production of pro-inflammatory cytokines, which increase glycolysis and further compromise mitochondrial functions. ·         All these factors together may contribute to mitochondrial exhaustion and indicate that the demand for extra ATP upon the commencement of increased activity cannot be met. ·         In conditions of chronic inflammation and oxidative stress, high NF-κB and low p53 may conspire to promote neuron and glial cell survival at a price of severely compromised metabolic brain function.
Chronic fatigue syndrome and/or fibromyalgia as a variation of antiphospholipid antibody syndrome: an explanatory model and approach to laboratory diagnosis	Chronic Fatigue and/or Fibromyalgia have long been diseases without definition. An explanatory model of coagulation activation has been demonstrated through use of the ISAC panel of five tests, including, Fibrinogen, Prothrombin Fragment 1+2, Thrombin/ AntiThrombin Complexes, Soluble Fibrin Monomer, and Platelet Activation by flow cytometry. These tests show low level coagulation activation from immunoglobulins (Igs) as demonstrated by Anti-B2GPI antibodies, which allows classification of these diseases as a type of antiphospholipid antibody syndrome. The ISAC panel allows testing for diagnosis as well as monitoring for anticoagulation protocols in these patients.
Transcriptional control of complement activation in an exercise model of chronic fatigue syndrome	Complement activation resulting in significant increases of C4a split product may be a marker of postexertional malaise in individuals with chronic fatigue syndrome (CFS).
Complement activation in a model of chronic fatigue syndrome	Exercise challenge induced significant increases of the complement split product C4a, but not C3a or C5a, at 6 hours after exercise only in the CFS group (P <.01), regardless of allergy status.
Differential heat shock protein responses to strenuous standardized exercise in chronic fatigue syndrome patients and matched healthy controls	These preliminary findings suggest an abnormal or defective adaptive response to oxidative stress in CFS, and raise the possibility that HSP profiling may provide a more objective biologic marker for this illness
Chronic fatigue syndrome combines increased exercise-induced oxidative stress and reduced cytokine and Hsp responses.	The response of CFS patients to incremental exercise associates a lengthened and accentuated oxidative stress, which might result from delayed and insufficient Hsp production.

Antibodies in ME/CFS

References	ME/CFS Antibodies
In myalgic encephalomyelitis/chronic fatigue syndrome, increased autoimmune activity against 5-HT is associated with immuno-inflammatory pathways and bacterial translocation	·         The incidence of positive autoimmune activity against 5-HT was significantly higher (p<0.001) in ME/CFS (61.5%) than in patients with Chronic Fatigue (13.9%) and controls (5.7%). ·         ME/CFS patients with 5-HT autoimmune activity displayed higher TNFα, IL-1 and neopterin and increased IgA responses against LPS of commensal bacteria than those without 5-HT autoimmune activity. ·         Anti-5-HT antibody positivity was significantly associated with increased scores on hyperalgesia, fatigue, neurocognitive and autonomic symptoms, sadness and a flu-like malaise.
Autoantibodies against muscarinic cholinergic receptor in chronic fatigue syndrome	Human muscarinic cholinergic receptor 1 (CHRM1), mu-opioid receptor (OPRM1), 5-hydroxytryptamine receptor 1A (HTR1A) dopamine receptor D2 (DRD2) ·         The mean anti-CHRM1 antibody index was significantly higher in patients with CFS (p<0.0001) and autoimmune disease (p<0.05) than that in healthy controls, and positive reaction was found in 53.3% of patients with CFS. ·         Anti-OPRM1 antibodies, anti-HTR1A antibodies, and anti-DRD2 antibodies were found in 15.2, 1.7, and 5.0% of patients with CFS, respectively. ·         Anti-nuclear antibodies were found in 56.7% (34/60) of patients with CFS, but anti-nuclear antibody titers did not correlate with the activities of the above four autoantibodies
Reduction of [(11)C](+)3-MPB Binding in Brain of Chronic Fatigue Syndrome with Serum Autoantibody against Muscarinic Cholinergic Receptor	The present results demonstrate that serum autoantibody against the muscarinic cholinergic receptor (mAChR) can affect the brain mAChR without altering acetylcholinesterase activity and cognitive functions in CFS patients.
Anticardiolipin antibodies in the sera of patients with diagnosed chronic fatigue syndrome	Anticardiolipin antibodies (ACAs): ·         Immunoglobulin M isotypes in 95% of CFS serum samples tested. ·         The presence of immunoglobulin G and immunoglobulin A isotypes were also detected in a subset of the samples. ·         Future studies will focus on elucidating whether alterations to mitochondrial inner membranes and/or metabolic functions play a possible role in the expression of ACAs.
Infection, vaccination, and autoantibodies in chronic fatigue syndrome, cause or coincidence?	Antibodies testet in CFS. Antibodies in AIDs ·         Anti-dsDNA No ·         Anti-Sm No ·         Anti-RNP No ·         Anti-SS-A/Ro No ·         Anti-SS-B/LA No ·         Anti-Scl-70 No ·         ANA Yes Nuclear components ·         Laminin B1 Yes ·         68/48-kDa nuclear proteina Yes ·         p80-coilin nuclear proteinb Yes Phospholipid antibodies ·         Antiphosphatidylinositolc Yes Antibodies to CNS components ·         Serotonin Yes ·         ACTH Yes ·         CHMR1 Yes ·         MAP2 Yes Antibodies to diverse microorganisms ·         Gram-negative  enterobacteriaYes Coxiella burnetii (Q fever) Yes
IgM-mediated autoimmune responses directed against anchorage epitopes are greater in Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS) than in major depression	Serum IgM antibodies to the three anchorage molecules (palmitic and myristic acid and S-farnesyl-L-cysteine) and NO-phenylalanine were significantly higher in ME/CFS than in depression. The autoimmune responses to oxidatively, but not nitrosatively, modified self-epitopes were significantly higher in ME/CFS than in depression and were associated with fatigue and physio-somatic symptoms.
Antibody to Epstein-Barr Virus Deoxyuridine Triphosphate Nucleotidohydrolase and Deoxyribonucleotide Polymerase in a Chronic Fatigue Syndrome Subset	Antibodies to EBV EA(D) and neutralizing antibodies against the encoded-proteins EBV DNA polymerase and deoxyuridine triphosphate nucleotidohydrolase (dUTPase) were present in the EBV subset CFS patients. Of the sera samples obtained from patients with CFS 93.9% were positive for EA(D), while 31.6% of the control patients were positive for EBV EA(D). Serum samples were positive for neutralizing antibodies against the EBV-encoded dUTPase (23/52; 44.2%) and DNA polymerase (41/52; 78.8%) in EBV subset CFS patients, but negative in sera of controls.

Postural Orthostatic Tacycardia Syndrome, Orthostatic Intolerance, dysautonomia autoantibodies

References	POTS, OI, dysautonomi autoantibodies
Autoimmunoreactive IgGs from patients with postural orthostatic tachycardia syndrome	Forty unique proteins were identified and these include proteins that are associated with cardiac hypertrophy (mimecan, myozenin), cardiac remodeling (periostin), cardiomyopathy (desmin, desmoplakin), cell survival (laminin), structural integrity (filamin), chaperone proteins (crystalline, HSP70), mitochondrial enzymes, and channel proteins.
Autoimmunoreactive IgGs against cardiac lipid raft-associated proteins in patients with postural orthostatic tachycardia syndrome	The targets of autoimmunoreactive IgGs include proteins associated with caveolae structure, adrenergic signaling, calcium signaling, cytostructures, chaperone and energy metabolism. Multiple pathways were involved including those that regulate caveolae-mediated signaling, oxidative phosphorylation, fatty acid metabolism, protein ubiquitination, and cardiac β-adrenergic signaling. ·         Desmin ·         HSP70 ·         Cavin-1
Autoantibody activation of beta-adrenergic and muscarinic receptors contributes to an "autoimmune" orthostatic hypotension	Activating autoantibodies to β1/2-adrenergic (AAβ1/2AR) and M2/3 muscarinic receptors (AAM2/3R) are present in some patients with idiopathic OH compatible with an in vivo effect.
Agonistic autoantibodies as vasodilators in orthostatic hypotension: a new mechanism	We have identified the presence of autoantibodies to β2-adrenergic and/or M3 muscarinic receptors by ELISA in 75% (15 of 20) of patients with significant orthostatic hypotension. Antibody activation of vascular β2 and/or M3 receptors may contribute to systemic vasodilation.
Drug-like actions of autoantibodies against receptors of the autonomous nervous system and their impact on human heart function	Among the epitopes targeted are first and second extracellular loops of the β-adrenergic (β-adrenoceptor) and M2 muscarinic receptor. β(1)-adrenoceptor autoantibodies affect radioligand binding and cardiomyocyte function similar to agonists. In conclusion, such autoantibodies (Antibodies against cholinergic and adrenergic receptors) seem to cause or promote chronic human left ventricular dysfunction by acting on their receptor targets in a drug-like fashion.

Almindelig træning forværrer ME patienters tilstand

Det centrale sygdomselement i ME er, at patienterne får det værre efter aktivitet, som er ud over deres meget snævre grænser.

Dette symptom er så karakteristisk for sygdommen, at måling af konditionen er foreslået anvendt som diagnostisk test.

Workwell Foundation har udsendt en pressemeddelelse med dette budskab:  Has Workwell Foundation Identified a Diagnostic Biomarker for Chronic Fatigue Syndrome?

Citat fra pressemeddelese:
"Workwell Foundation announces the publication of a new study supporting previous findings that a 2-day Cardiopulmonary Exercise Test (CPET) protocol objectively documents post-exertional malaise (PEM), the most commonly recognized symptom in Chronic Fatigue Syndrome/Myalgic Encephalomyelitis (CFS/ME). The study revealed a statistically significant performance decrease on Day 2 in workload at ventilatory threshold (VTWL), workload at peak exercise (WLpeak), volume of oxygen consumed at ventilatory threshold (VTO2) and volume of oxygen consumed at peak exercise (VO2peak). In short, individuals with CFS/ME were unable to reproduce their Day 1 performance on Day 2. The statistical classification analysis points to a diagnostic biomarker for CFS/ME with a 95.1% accuracy."

Eller sagt på jævnt dansk, når en ME patient foretager en konditionstest to på hinanden følgende dage, vil resultatet på dag 2 være væsentligt forringet, fordi patienten ikke er kommet sig efter konditionstesten på dag 1.

Metoden kan naturligvis ikke anvendes til de mest syge, som er sengeliggende og ikke har kræfter til en konditionstest.

Det er så enkelt at opdage sygdommens natur med konditionstest, at man kan undres over, hvorfor der er så meget besvær med at stille diagnosen og så megen diskussion om sygdommen er fysisk er psykisk.

Diagnose ved kondtionstest skal naturligvis foretages i regi af læger, ligesom læge og  ME patient skal også være klar over forværringen, der medfølger af at gennemføre testen.

Her er et eksempel på en moderat syg ME patient, som har fået foretaget to konditionstest med en måneds mellemrum. Patienten og lægen vidste på det tidspunkt IKKE, at patienten havde ME, og der blev derfor sat ind med et motionsprogram mod patientens udmattelse: 15-20 minutters moderat motion på kondicykel 2-3 gange om ugen.

Her er resultat af første konditionstest - altså FØR motionsprogram:

Og her er resultat af anden konditionstest - EFTER gennemførelse af motionsprogram:

Patienten her fik altså forværret sin tilstand med et almindelig let motionsprogram, hvor det tog mange uger efter at komme sig. ME patienten trodsede sin udmattelse, fordi "det var det, der skulle til for at komme i gang igen".

ME eksperter har udarbejdet egnede motions/aktivitetsprogrammer til ME patienter, således patientens grænse ikke overskrides. Og der er beskrivelser af  tilfælde, hvor ME patienterne har fået forbedret deres tilstand ved at følge disse vejledninger. Her er en beskrivelse af et sådant tilfælde:

FUNCTIONAL OUTCOMES OF ANAEROBIC REHABILITATION IN A PATIENT WITH CHRONIC FATIGUE SYNDROME: CASE REPORT WITH 1-YEAR FOLLOW-UP

Historien er grundigt gennemgået på Cort Johnsons blog Health Rising:

Heart Rate Monitor Program Improves Heart Functioning in Chronic Fatigue Syndrome (ME/CFS)

Danske ME patienter har brug for, at danske læger tager denne viden i brug. Og det er yderst vigtigt, at ME patienter sætter sig grundigt ind i viden førend de i samarbejde med ME uddannede læger påbegynder et aktivitets/motionsprogram. Forværring MÅ ikke forekomme.  

Det er også vigtigt, at ME patienten føler sig TRYG ved at gennemføre et motions/aktivitetsprogram i samråd med sin læge. Dette kan f.eks. gøres ved, at patienten anvender pulsur, hvorefter læge og patient sammen kan gennemgå resultater og hele tiden løbende tilpasse programmet.

Det handler ikke bare om at gennemføre et aktivitetsprogram for at optimere sit helbred, det handler også om god livskvalitet IMENS man gør det!!!

Det kan være meget, meget svært for udenforstående at fatte den lille bitte mængde aktivitet de mest syge ME patienter kan tåle, så lad mig lige bringe et citat fra denne anerkendte vejledning fra USA:

"Homebound and bedbound patients may benefit from in-home services that provide assisted range-of-motion and strengthening exercises. Exercise lying down should be advised when exercise standing or sitting is poorly tolerated. Initially, interval training exercise should begin with gentle stretching to improve mobility utilizing intervals of 90 seconds or less."

At nogen får det bedre, når de lærer at styre aktivitetsniveauet, og at der er enkelte solstrålehistorier om gode forbedringer, er ikke det samme som, at nu har vi kuren mod ME. Hvis man kunne motionere sig rask i et snuptag, så var der nok ikke millioner af ME syge mennesker verden over.

Automatic Lung Parameter Estimation - useful for ME patients?

I like to keep an eye on new technology that can be useful for ME patients. And this time I found ALPE.

ALPE (Automatic Lung Parameter Estimation) is a product from Mermaid Care in Denmark. Their vision is:

“to make ALPE (Automatic Lung Parameter Estimation) the International Clinical Standard for diagnosing and characterizing the Pulmonary Gas Exchange. Our expertise in Pulmonary Gas Exchange Diagnostic is helping healthcare professionals in new ways to predict, diagnose and treat disease.”´

ALPE essential characterizes the pulmonary gas exchange and is used to minimize and document pulmonary complications during the anesthesia process. It makes an optimal preoperative pulmonary diagnostic for patients with shortness of breath.

ME patients have Diminished Cardiopulmonary Capacity During Post-Exertional Malaise (PEM).

Workwell Foundation uses cardiopulmonary exercise testing (CPET) in ME diagnostic.

Snell et al. have recently publiced this article on the subject: Discriminative Validity of Metabolic and Workload Measurements to Identify Individuals With Chronic Fatigue Syndrome

And ME patients are frequently in a state of PEM. Furthermore ME patients don’t tolerate Anesthesia very well.

Some ME patients have the co-morbidity Postural Orthostatic Tachycardia Syndrome (POTS), and this syndrome is associated with hemodynamic instability.

This makes ME patients a vulnerable group of patients during anesthesia, so maybe a close monitoring with ALPE is a good idea?

Project proposal: Plasma analysis of low abundance proteins in serum from ME patients after exercise

I would like to understand why ME/CFS patients get Post Exertional Malaise (PEM). We have read it again and again: PEM following physical activity are hallmark symptoms of ME/CFS and may even qualify for biomarker status. The latest fine paper on this subject is:
Discriminative Validity of Metabolic and Workload Measurements to Identify Individuals With Chronic Fatigue Syndrome

And some biochemistry do go wrong after exercise:
Differences in metabolite-detecting, adrenergic, and immune gene expression following moderate exercise in chronic fatigue syndrome, multiple sclerosis and healthy controls

If ME/CFS patients perform worse 24 hours after excercise and feel ill, there must be something in the blood/plasma to show it. There are so much advanced technology, it can't be that hard to find it!

Agilent is every nerd's dream of advanced technology. So I searched the site for a good idea, and you may be the judge of what I came up with:

My project proposal: "Plasma analysis of low abundance proteins in serum from ME/CFS patients after exercise."

We do the usual trick: We find a group af ME/CFS patients and a suitable control group. They do the exercise test, and we collect blood samples before and after exercise. We can collect blood samples 30 minutes, 8 hours, 24 hours, 48 hours after excercise.

And now for the advanced technology. We use the plasma from the blood samples, but not the "standard plasma", we make a purifed plasma. From this Agilent poster:

Multi-Dimensional Workflow Approach for Human Plasma Analysis

I have this knowledge:

Plasma is a unique sample, possessing proteins that span the entire human proteome. Analysis of plasma can provide valuable information for the discovery of new biomarkers and novel drug targets. However, the tremendous complexity of the plasma proteome presents extreme analytical challenges in proteome characterization.

High abundant proteins comprise up to 90% of the total protein mass in the plasma. Agilent has developed a method to remove the top 7 high-abundant proteins in plasma. Then you are left with a sample of low abundance proteins for further analysis.

Agilent has a lot of equipment to characterize the low abundance proteins. And they have RESEARCH GRANTS!

Now I just need some scientists and a lab to my project proposal...