Are Infections Just a Trigger of ME/CFS, or an Ongoing Cause of ME/CFS?

[Hip]

I have never come across reference to this RNase L at scientific meetings - only on PR. Do we actually have any reproducible data about it in ME, or is it another unconfirmed report from a private lab?

Actually I have never properly looked up the original papers on the fragmented, low molecular weight RNase L found in ME/CFS, so perhaps it's high time I did. There was talk of this fragmented RNase L some years ago, because it was hoped it would serve as a biomarker for ME/CFS. But I understand that later it turned out that you also get fragmented RNase L in multiple sclerosis, and furthermore, it turned out that not all ME/CFS patients have this fragmented RNase L.

Essentially, RNase L normally has a molecular weight of 80 or 83 kiloDaltons (not sure which, as I have seen both these figures), but in ME/CFS you also find an RNase L isoform weighing 37 kDa.

However, in the last 5 years or so, I have heard little more about this line of research. It seems to have been forgotten.

Here are some of the studies I found on the fragmented RNase L in ME/CFS:

Biochemical evidence for a novel low molecular weight 2-5A-dependent RNase L in chronic fatigue syndrome J Interferon Cytokine Res. 1997.

This paper found the ratio of fragmented RNase L to normal RNase L correlated with the degree of disability of ME/CFS patients:
Biochemical Dysregulation of the 2-5A Synthetase/RNase L Antiviral Defense Pathway in Chronic Fatigue Syndrome Journal of Chronic Fatigue Syndrome. 1999.

Structural and functional features of the 37-kDa 2-5A-dependent RNase L in chronic fatigue syndrome J Interferon Cytokine Res. 2002 Apr.

RNase L levels in peripheral blood mononuclear cells: 37-kilodalton/83-kilodalton isoform ratio is a potential test for chronic fatigue syndrome Clin Diagn Lab Immunol. 2003 Mar.

This paper found that there was high variability and poor reproducibility of the 37/83 ratio for CFS patients, presumably indicating difficulties in using this as a biomarker:
Variability of the RNase L Isoform Ratio (37 Kilodaltons/83 Kilodaltons) in Diagnosis of Chronic Fatigue Syndrome Clin Vaccine Immunol. February 2005.

This review paper surveys the research of RNase L in ME/CFS:
Impairments of the 2-5A Synthetase/RNase L Pathway in Chronic Fatigue Syndrome Anticancer Research. 2005.

These papers find and up-regulation of RNase L in ME/CFS:

Upregulation of the 2-5A synthetase/RNase L antiviral pathway associated with chronic fatigue syndrome Clin Infect Dis. 1994 Jan.

This paper finds a deficiency of the RNase L Inhibitor (RLI) gene mRNA in ME/CFS, which it says may explain the increased RNase L activity in ME/CFS:
Downregulation of RNase L inhibitor correlates with up regulation of interferon-induced proteins (2-5A synthetase and RNase L) in patients with chronic fatigue immune dysfunction syndrome J Clin Lab Immunol. 1998.

In terms of what might be cleaving RNase L into low molecular weight chunks, elastase, m-calpain, and cathepsin G have been proposed as possible culprits.



My own interest in fragmented RNase L stems from my speculative idea that this might help explain why the intracellular non-cytolytic enterovirus infections (which comprise viral ssRNA and dsRNA) are not cleared from the cells in ME/CFS. The function of RNase L is of course to destroy RNA, viral or host, in the cell.

Since RNase L is interferon-induced, and since John Chia's interferon studies showed that enteroviral RNA was present in the PBMC of ME/CFS patients before IFN treatment, but disappeared afterwards, presumably RNase L is playing an important role in clearing out enteroviral RNA from cells. So if there were any dysfunction in the RNase L pathway, it might hamper this viral clearance.

 

[msf]

Prof. Edwards, I think you should point out that the rheumatologists are not all agreed on this point - I would guess that if you googled the last 10 reviews of reactive arthritis on Pubmed, at least 5 would say that the evidence suggests that the disease process is driven by the persistence of the triggering pathogen.

 

[Hip]

There is also one major problem in your analogy, enteroviruses are so easy to catch over and over again. Unlike hepatitis C which can only be passed through sexual contact or sharing needles etc, if you had to do year long interferon treatment or 12 weeks/$85,000 harvoni or other next gen treatment you would likely catch enterovirus again soon after being cured. And do you do this over and over again? It's not feasible.

I don't think you would catch the same coxsackievirus B or echovirus serotype again if it had been eradicated from you body, because your immune memory would retain the antibodies to that virus, and this would prevent reinfection.

 

[lansbergen]

I don't think you would catch the same coxsackievirus B or echovirus serotype again if it had been eradicated from you body, because your immune memory would retain the antibodies to that virus, and this would prevent reinfection.

You think enough antibodies stay forever?

 

[leokitten]

I don't think you would catch the same coxsackievirus B or echovirus serotype again if it had been eradicated from you body, because your immune memory would retain the antibodies to that virus, and this would prevent reinfection.

I understand that but come on there are at least 30 serotypes of coxsackievirus alone not to mention all the others, it's just not a feasible approach to do a year's worth of tough IFN treatment to eradicate a serotype or two. When it comes to viruses that are so easy to catch and are pretty ubiquitous there needs to be a different approach, we need to understand why the immune system in some people don't work properly and keep these pathogens in check and treat this.

 

[Jonathan Edwards]

Prof. Edwards, I think you should point out that the rheumatologists are not all agreed on this point - I would guess that if you googled the last 10 reviews of reactive arthritis on Pubmed, at least 5 would say that the evidence suggests that the disease process is driven by the persistence of the triggering pathogen.

I think 99% of rheumatologists must be agreed on this point. If they were not they would be re-treating their patients with antibiotics every time they had a new lesion come up in a new joint. I have never met a rheumatologist who would take this seriously. If you google reviews you may well find that half of them try to argue that live bacteria are still present. But people who write reviews tend to be enthusiasts and enthusiasts working on reactive arthritis tend to look for bacteria because they cannot cope with anything more complicated like T cell addressin domains. I have seen this story go round and round since the 1980s, even in my own department, and my professional bacteriology colleagues and I have always agreed that the data would not pass standard diagnostic lab quality control.

Another point is that we now routinely treat these people with TNF blockade and at the time I retired from rheumatology I had not heard of a single case of reactivation of a putative initiating infection on TNF blockade. That is pretty strange if bacteria are still there because we know that where bacteria ARE still there, as in TB, TNF blockade frequently reactivates severe disseminated infection. I am afraid the silence from these little germ chaps is pretty deafening.

 

[msf]

Just the first one I googled, I assume they are a reputable organisation.

- https://www.rheumatology.org/Practice/Clinical/Patients/Diseases_And_Conditions/Reactive_Arthritis/

This agrees with most of the reviews I have read (these were not the ones that took an extreme position) in stating that the evidence suggests that antibiotics may be effective in Ctr-triggered ReA.

 

[msf]

On the aptly-named 'Up to Date,' they talk about antecedent or concomitant infections: http://www.uptodate.com/contents/reactive-arthritis

 

[msf]

In their words: Reactive arthritis has been defined by consensus as a form of arthritis that is associated with a coexisting or recent antecedent extraarticular infection.

 

[msf]

Antibiotic therapy should be used for treatment of active Chlamydia trachomatis infection, if present. In general, antibiotics are not indicated for uncomplicated enteric infections or for treatment of the arthritis itself. (See 'Genitourinary tract infection' above and 'Enteric infection' above and 'Treatment of the infection'above.)

 

[Hip]

You think enough antibodies stay forever?

No, but even if the antibodies stick around for just 10 years, that's very helpful.

Anyway, the chances are that you will not be exposed to the same coxsackievirus B / echovirus infection again, because unlike herpes family viruses, which are ever-present in the population, enteroviruses only appear in epidemic outbreaks.

Outbreaks of a given enterovirus serotype may last a couple of years, but then will disappear, not to be seen again for decades sometimes.

You may potentially be exposed to another coxsackievirus B / echovirus serotype in the future, but that may not cause ME/CFS. It may be only certain serotypes that cause ME/CFS in a given patient.

If you want some evidence of this, then note that people may develop ME/CFS after a single enteroviral infection, but on viral testing, these ME/CFS patients often show the presence of several coxsackievirus B / echovirus serotypes in their blood, which indicates that at an earlier stage in their life, they must have had these viruses in their body without ME/CFS appearing.

So you should not assume that every coxsackievirus B / echovirus is going to cause ME/CFS.

Dr Chia also uncovered some evidence that the immunological conditions in your body at the time you first caught the enterovirus may play a major role in whether you later develop ME/CFS from it (see this thread on corticosteroids). So even if you did catch the same virus again, after it had been eradicated from your body, it may not cause ME/CFS the second time around.

I understand that but come on there are at least 30 serotypes of coxsackievirus

The coxsackievirus A group is not associated with ME/CFS, it is only coxsackievirus B (which has 6 serotypes) that is linked to ME/CFS.

 

[lansbergen]

So you should not assume that every coxsackievirus B / echovirus is going to cause ME/CFS.

As I said before I think it is just an oportunist.

 

[Jonathan Edwards]

Antibiotic therapy should be used for treatment of active Chlamydia trachomatis infection, if present. In general, antibiotics are not indicated for uncomplicated enteric infections or for treatment of the arthritis itself. (See 'Genitourinary tract infection' above and 'Enteric infection' above and 'Treatment of the infection'above.)

Yes, of course you treat for the presumed infection at presentation if appropriate.

The ACR are respectable. They say 'New research suggests that a prolonged course of two or more antibiotics might be effective in patients with chronic Chlamydia-induced reactive arthritis. However, more studies are needed.' which basically means that the enthusiasts have done another inconclusive study, as always, and don't hold your breath. Why is the situation still inconclusive when the enthusiasts have been doing this since the 1980s? Why don't patients given broad spectrum antibiotics for other reasons ever report suddenly going in to remission? Why are there a more or less identical diseases (peripheral ank spond and psoriatic arthropathy) that appear to have no relation to infection?

I may have fringe views on some things but there is nothing fringe about my view here.

 

[msf]

No, it's because the study was done in 2010, and the no one has replicated it yet. I have read most of the trials of antibiotics in ReA, and the two that were the best designed (in that they tried to measure persistence in the patients) were the ones that found a positive effect for antibiotics, along with a decrease in IgA antibodies to the triggering organism, and a decrease in antigen levels as detected by PCR. Another study that wasn't so well designed found that antibiotics did not have an effect, but when they reviewed the two groups (placebo and drug) several years later they found that there was a long-term beneficial effect.

 

[msf]

Also, are Americans rheumotologists more polite, or more circumspect than British ones? If the American College of Rheumotologists thought it was inconclusive, why wouldn't they say it? And why does Uptodate disagree with you?

 

[Hip]

As I said before I think it is just an oportunist.

I don't think "opportunist" is quite the way I tend to view it; I think it could be more that enterovirus or say EBV "teams up" with other factors present in the body to create ME/CFS. In other words, if the other factors had not been present at the time of first catching the virus, ME/CFS may not have developed. That's an idea I often toy with, in terms of ME/CFS theories.

One thing that really interests me is the very high level of comorbidity of IBS in ME/CFS patients. I had severe IBS-D for five years before catching the virus that appeared to precipitate my ME/CFS. I think this IBS condition could have "teamed up" with my virus to create ME/CFS.

 

[Jonathan Edwards]

Also, are Americans rheumotologists more polite, or more circumspect than British ones? If the American College of Rheumotologists thought it was inconclusive, why wouldn't they say it? And why does Uptodate disagree with you?

They did say it. If the data were conclusive there would be no need for further studies. 'Might' implies lack of certainty in my dictionary! I didn't see where UpToDate disagreed. Some reactive arthritis is associated with ongoing infection - Poncet's disease for instance where the inciting organism is Mycobaterium tuberculosis. But this is a rarity.

 

[msf]

If you agree that some reactive arthritis is associated with ongoing infection but emphasise that this is rare (something the UptoDate article did not do) that is fine, I just think it is unhelpful to patients to ignore this possibility completely. I took issue with what you said because I thought you were suggesting that this never happens.

 

[halcyon]

Let's go over some of the past autopsy findings on ME patients.

Behan, Gow, and Mcgarry published findings from a patient that committed suicide. Sadly the full text isn't available, there is only this excerpt:

Positive PCR sequences were deteced in the muscle, heart, and brain samples from the hypothalamus and brain stem region of our patient with this syndrome. Sequence analyses on the PCR products were compatible with exogenous virus and not with contamination. The results showed and entervirus with an 83% similarity to Coxsakievirus B3.

Sadly no mention of any actual tissue damage one way or another, perhaps they do discuss this in the full paper.

Byron Hyde writes about findings from one of John Richardson's patients that commited suicide:

Circa 1996, an autopsy was performed on a woman with Myalgic Encephalomyelitis in Newcastle-upon- Tyne by Dr John Richardson and the brain tissue examined by Dr. James Mobray at St Mary's Paddington. This woman had a history of typical Myalgic Encephalomyelitis, was well known by Dr Richardson and accidentally died when her car fell off the side of the pier into the North Atlantic, the cold water preserving the brain tissue. Dr Mowbray was able to demonstrate an autoimmune inflammatory injury at the capillary level of the brain and basement membrane, the area that separates the capillaries from the neurons and brain tissue. In effect the same juxtaposition as in poliomyelitis but in this case in the brain and not in the spinal cord. (Poliovirus also injures the sub cortical areas of the brain.)

Sadly no mention of any viral findings in the damaged tissue. Dr. Mowbray I believe pioneered the use of the VP1 enterovirus test so I can't imagine he wouldn't have tested these samples for virus. I'm not sure if the details of this autopsy are published anywhere, I haven't been able to find it if so.

John Richardson published the details of another one of his patients that committed suicide:

Pathology reports are as follows: Paraffin section from cerebral cortex; Immunoperoxidase staining with monoclonal D8-1 against enteroviral VPI protein.

There is staining of cytoplasm of fibroblasts around small vessels. In addition there is patchy distribution of stain in isolated glial cells throughout the section. Only a small fraction of all the glial cells are stained. Specificity confirmed by absence of staining of glial cells or perivascular fibroblasts with either normal mouse serum or a control mouse monoclonal antibody to dengue virus.

DNA probe report: Enterovirus-specific cDNA probes labelled with biotin and hybridized in situ on formalin fixed and paraffin-embedded 5 micron sections of autopsy material from cerebral hemispheres.

Results: Positive hybridization signals were observed in the form of dense brown staining of glial cells and fibroblasts in the adventitia of small blood vessels. No hybridization was observed in control adjacent sections hybridized with a control biotin labelled vector plasmid clone.

This would seem to tie together the previous two findings, but again sadly no mention of actual damage to these small blood vessels where virus was found so it's hard to say.

These findings of damage and infection of cerebral blood vessels are interesting in light of the SPECT/SPET findings of British and North American researchers, who find evidence of cerebral hypoperfusion. It's interesting to me because there are similar SPECT findings of hypoperfusion in both acute and chronic enteroviral infections of the CNS. 1 2 3

 

[Oredogg]

People have been saying EBV is a necessary cofactor for disease X since the 1980s at least. It is very plausible that B cell mediated diseases require the transforming effects of EBV to get started but as far as I know this is pretty untestable and remains unproven across the board. Even in Burkitt lymphoma, which gave EBV the name 'Cancer Virus' does not seem to be dependent on the transforming effect despite the fact that it would seem obvious that it would. So I agree that it is possible that EBV is a necessary cofactor for MS but that is rather different from what people tend to mean by trigger. EBV infection is mostly in infancy. MS occurs mostly around 20-40.

I have never heard of the idea of EBV being involved in demyelination before. The MS community are divided in opinions on virtually everything and although you are bound to find a review article pushing one theory or another I think this is largely a reflection of the proliferation of review journals that make money out of science by distributing drivel.

The other point is that we do not know that MS is autoimmune. It may well be, but so far what we know is that antibodies are made in the wrong tissue (brain), not that these antibodies are necessarily directed against self. There are lots papers suggesting that they are directed against myelin proteins but when I last looked at the field I was not convinced that this was a hard finding.

My feeling is that both in MS and ME we may need to change gear on our ideas about antibodies. Here is an example hypothesis. For antibodies to be 'anti-X' in a functional way in plasma they really need to have a dissociation constant of something like ten to the power minus 8. However, if they are picked up by immunoglobulin Fc receptor 1 (CD64) then because of the thermodynamic stabilisation of receptor binding they may function as 'anti-X' with a dissociation constant of - say - 10 to the -6. In most tissues this does not matter much because a macrophage with CD64 receptors will pick up a random assortment of antibodies and so only a tiny fraction will function as anti-X and nothing will notice. However, if a microglial cell with CD64 in the brain is bathed in oligoconal antibody that is anti-X at a 10 to the -6 level it may gobble up X. Since low affinity often goes with broad specificity there is a reasonable chance that some myelin protein will stick at 10 to the -6 so you have lift off. But if you do standard ELISA assays for autoantibodies with vigorous washing that only leave 10 to the -8 binding on the pate you will never know. (The actual numbers are made up here, you will realise.)

So maybe in ME we have some antibodies to endothelial cell receptors or neurotransmitter receptors which you will never find in an ELISA. They will only function if bound to CD64. And the result of CD64 binding may be interferon production. Gamma interferon switches CD64 on, so you might have the possibility of continued grumbling interferon production very locally with no other signs of inflammation. I doubt all of that will hang together but it is the sort of idea I think we may need to consider.

I am also keen on this idea of possible anti-endothelial or anti-neuronal antibodies and agree that ELISA may not be enough. My inner pathologist wonders why we couldn't study bound immunoglobulin in patient/controls in neuronal or vascular tissues, akin to how we diagnose anti-GBM in renal biopsies, with immunofluorescence amplification. It could be as simple as taking several skin punch biopsies. Thoughts?