Chronic coxsackievirus B (CVB) infection is associated with ME/CFS -- Is Rituximab relevant?

[M Paine]

There's a lot to say about all of those papers. Individually, each one could be discussed at length. I think the point that Dr Edwards may be eluding to, is so far there has not been a conclusive study which can definitively connect Coxsackie, or any Virus, to ME. That's not to say it's not related in some way, but at this point in time, it's not conclusive.

If we really want to get to the bottom of the Viral question, the best place for that is at the Columbia Center for Infection and Immunity. Very few labs are properly equipped to assess patient samples properly, and rely heavily instead on immune response markers, specific primers, or very limited RNA sequencing.

 

[Jonathan Edwards]

Now I am confused! So in your opinion, there is no connection between Coxsackie virus and ME? I do not know the answer but had assumed this was an established fact (that at least one subgroup of ME has an EV). Versus my illness turned out to be autoimmune subgroup etc.

My comment was specifically about chronic coxsackie infection. Coxsackie virus may precipitate outbreaks of post-viral fatigue, which may in some cases extend to diagnosable ME/CFS. But that is a different matter from chronic infection being established as more common in ME than healthy people. The answer to what I make of all the quoted studies is not much. One or two suggest there might be more coxsackie in ME patients but each study has a significant weakness and when people like Mady Hornig have gone back and systematically looked for viruses they found zilch if I remember rightly.

 

[halcyon]

One or two suggest there might be more coxsackie in ME patients but each study has a significant weakness and when people like Mady Hornig have gone back and systematically looked for viruses they found zilch if I remember rightly.

So you're willing to dismiss dozens of studies you haven't read in detail with unpublished data from one researcher?

 

[Jonathan Edwards]

So you're willing to dismiss dozens of studies you haven't read in detail with unpublished data from one researcher?

Yes, because I have read enough to see that no firm conclusion can be drawn. In science one has to develop a rapid way of filtering studies and these do not add up to any firm evidence. If there is validity in an observation one can be pretty sure that if someone comes along with good methodology and tries to repeat it they will get at least some hint of the same result - but zilch. And it is not just Mady Hornig. Others trying to repeat such findings have found nothing. Publication bias always means that you get five dubiously positive studies for every one reliably negative one.

 

[Gijs]

Yes, because I have read enough to see that no firm conclusion can be drawn. In science one has to develop a rapid way of filtering studies and these do not add up to any firm evidence. If there is validity in an observation one can be pretty sure that if someone comes along with good methodology and tries to repeat it they will get at least some hint of the same result - but zilch. And it is not just Mady Hornig. Others trying to repeat such findings have found nothing. Publication bias always means that you get five dubiously positive studies for every one reliably negative one.

Professor Edwards, Could different results not be due to the heterogeneity of this disease?

 

[Jonathan Edwards]

Professor Edwards, Could different results not be due to the heterogeneity of this disease?

To an extent they can, but if an attempt at confirmation finds nothing at all the much more likely explanation is that the initial finding was a red herring. If you set up a diagnostic category and try to establish cause yo have to assume at least some consistency in cohorts. Otherwise your diagnostic category has to be questionable.

 

[M Paine]

Ian Lipkins lab (same lab as Dr Hornig at Columbia) could not find a link to the pathogens they screened for (18 previously implicated pathogens in ME if I recall correctly) , however they were still looking at EBV (implying that their data for EBV was inconclusive). In addition, they are still seeking funding for their large scale Sequencing study, which will broaden the search.

 

[Hip]

Ian Lipkins lab (same lab as Dr Hornig at Columbia) could not find a link to the pathogens they screened for

At the time, I emailed Prof Lipkin to ask him if the high throughout sequencing method he used in that study would be able to detect the non-cytolytic enterovirus infections found in the tissues of ME/CFS patients.

Ian Lipkin told me that high throughout sequencing would not be able to detect such infections if blood samples were tested, but would be able to detect them if enterovirus-infected tissue samples were used. However, in this study, he did not test tissue samples, only blood samples, and if I remember correctly, CSF samples. Enterovirus is not really found in the blood and CSF in chronic infections; the virus resides in the tissues, as an intracellular infection.

So this means that the negative findings for enterovirus in Lipkin's paper don't really mean much. They certainly do not rule out enterovirus.

That's why the most interesting ME/CFS enterovirus studies to look at are the ones that perform enterovirus testing on muscle biopsies from ME/CFS patients. In the above list of studies, seven of them focused on muscle biopsies, and found that enterovirus RNA was much more commonly found in ME/CFS patients' muscles than in healthy controls.

 

[halcyon]

If there is validity in an observation one can be pretty sure that if someone comes along with good methodology and tries to repeat it they will get at least some hint of the same result - but zilch. And it is not just Mady Hornig. Others trying to repeat such findings have found nothing.

That's the point though, nobody has come along with good methodology. How do you know Hornig used good methodology when the data and how they obtained it remains unpublished? Nobody has tried to use the same methodology from the positive studies to reproduce the data. If people would actually read and understand the studies, and listen to what people like John Chia are saying, then we might get somewhere. Chronic enterovirus infections in ME do not involve viremia. As Chia has been saying for over 10 years now, finding enterovirus in one time serum/plasma samples with PCR is basically not worth trying. If you draw samples into PAXgene or Tempest blood tubes with RNA preservative, process the samples immediately, running a PCR assay capable of detecting double digit copy numbers per ml on buffy coat, and do this with repeat samples over the course of several weeks, if you're lucky you might get some hits. As far as I'm aware, no other studies have used this methodology. We've only seen single time PCR tests on serum/plasma, using what primers we don't know, on likely unpreserved banked blood that has been through who knows how many freeze/thaw cycles. I'm tired of hearing "we don't find viruses" from groups like OMF and CII that then refuse to publish their data.

To illustrate the point further, we can look at the recent mutant enterovirus D68 strain outbreak that started in 2014. An emergency RT-PCR assay was developed by the CDC to help diagnose cases. They refused to allow this assay to be used on only serum samples. They said the yield is too low. And this is for acute infections. It was required to pair serum with respiratory and/or rectal swabs, and the swabs were to be immediately placed in viral preservative before transport and tested or frozen immediately. Even with these stringent requirements, they could only isolate virus in about half of patients, and only found virus in CSF of a single patient. If it's this hard to find a single strain of one serotype of one enterovirus in acutely infected patients, imagine how well it's going to go trying to detect all strains of ~110 serotypes in a single blood compartment of patients with a chronic, low level infection. Until other teams start looking at tissue samples from ME patients with proper methodology, nobody has ruled out chronic enterovirus infection as a cause of ME.

 

[Hip]

@Gingergrrl this post may help answer your questions.

 

[Knockknock]

Interesting. Did you see the study on Dr Chia's website showing interferon B elimated chronic coxsackie in the heart in humans ? Anyone idea how this information ties in with that ?

I tested for cocakie and showed to be past infection, but im still concern that many of this viruses could be active or hidding deep in tissue or the cell and dont show.
Lab test for coxackie are very weak unless you go to specific infectious disease lab.
Any suggestions for acure testing??

 

[olegsel]

Recent studies have shown the clinical dangers of suppressing the humoral immune response with anti-CD20 monoclonal antibodies such as rituximab. Treatment with rituximab is routinely given to patients suffering from lymphomas, leukemias, transplant rejection and some autoimmune disorders. However, case reports describing EV meningoencephalitis following treatment with rituximab have been increasing in number (Servais, Caers et al., 2010;Schilthuizen, Berenschot et al., 2010). B cell-dependent immunosuppression following the administration rituximab as a therapy for lymphomas or leukemias would naturally reduce the level of circulating anti-CVB antibodies. If these protective antibodies suppress CVB replication in target tissues such as the CNS harboring persistent viral RNA, meningoencephalitis might be the outcome for some patients (Kiani-Alikhan, Skoulidis et al., 2009).

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4567421/

 

[Jonathan Edwards]

Recent studies have shown the clinical dangers of suppressing the humoral immune response with anti-CD20 monoclonal antibodies such as rituximab. Treatment with rituximab is routinely given to patients suffering from lymphomas, leukemias, transplant rejection and some autoimmune disorders. However, case reports describing EV meningoencephalitis following treatment with rituximab have been increasing in number (Servais, Caers et al., 2010;Schilthuizen, Berenschot et al., 2010). B cell-dependent immunosuppression following the administration rituximab as a therapy for lymphomas or leukemias would naturally reduce the level of circulating anti-CVB antibodies. If these protective antibodies suppress CVB replication in target tissues such as the CNS harboring persistent viral RNA, meningoencephalitis might be the outcome for some patients (Kiani-Alikhan, Skoulidis et al., 2009).

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4567421/

I think we need to be aware that such problems are extremely rare when rituximab is the only immunosuppressive factor involved - as would be the case for treating ME. Lymphoma itself interferes with antibody control. Rituximab for lymphoma innerly always given together with drugs that have a much more potent immunosuppressive effect - hitting innate as well as adaptive immune responses. Opportunistic infections are therefore quite common in the context of rituximab but that is a long way from saying that rituximab is a major factor, or even relevant. As a rule rituximab does not reduce antibody levels to pathogens in people with autoimmune disease. My lab has hundreds of measurements indicating that.

 

[JenB]

I'd love try and go do something about this, to figure out what evidence would be required to either strongly confirm or disconfirm this line of inquiry, who should do it, how to fund it, and how to push drug development. If interested: jennifer@meaction.net.