Discovery could lead to faster diagnosis for some chronic fatigue syndrome cases

[patient.journey]

http://www.plosone.org/article/info:doi/10.1371/journal.pone.0047891

Background

A defined diagnostic panel differentiated patients who had been diagnosed with chronic fatigue syndrome (CFS), based upon Fukuda/Carruthers criteria. This diagnostic panel identified an Epstein-Barr virus (EBV) subset of patients (6), excluding for the first time other similar “clinical” conditions such as cytomegalovirus (CMV), human herpesvirus 6 (HHV6), babesiosis, ehrlichiosis, borreliosis, Mycoplasma pneumoniae, Chlamydia pneumoniae, and adult rheumatic fever, which may be mistakenly called CFS. CFS patients were treated with valacyclovir (14.3 mg/kg q6h) for ≥12 months. Each patient improved, based upon the Functional Activity Appraisal: Energy Index Score Healthcare Worker Assessment (EIPS), which is a validated (FSS-9), item scale with high degree of internal consistency measured by Cronbach's alpha.
Methods

Antibody to EBV viral capsid antigen (VCA) IgM, EBV Diffuse Early Antigen EA(D), and neutralizing antibodies against EBV-encoded DNA polymerase and EBV-encoded dUTPase were assayed serially approximately every three months for 13–16 months from sera obtained from patients with CFS (6) and from sera obtained from twenty patients who had no history of CFS.
Results

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.
Conclusions

There is prolonged elevated antibody level against the encoded proteins EBV dUTPase and EBV DNA polymerase in a subset of CFS patients, suggesting that this antibody panel could be used to identify these patients, if these preliminary findings are corroborated by studies with a larger number of EBV subset CFS patients.

 

[AFCFS]

I have mentioned this elsewhere, but one of the guys who wrote that article, A. Martin Lerner, has a pretty interesting and informative website/practice: The Treatment Center for Chronic Fatigue Syndrome (CFS).

There are two long videos there that are pretty in depth, as well as other information on the site. What I don't get is this guy seems exceedingly qualified (see physician profile below), but in the videos there are just a handful of people in the audience. He looks to be getting up there in years, but think the videos are worth watching if someone has an interest in this route of research/practice.

Physician Profile

Certified by the American Board of Internal Medicine and is an Infectious Disease Specialist.

Residency, Internal Medicine, Harvard Medical Services. Boston City Hospital and Barnes Hospital, St. Louis, MO.

Washington University School of Medicine, M.D.
Two Years, National Institute of Allergy and Infectious Diseases, Epidemiology Unit.
Alumni Awardee, Washington University School of Medicine.

Three years research fellow in infectious diseases at the Thorndike Memorial Laboratory, Boston City Hospital and Harvard Medical School under the direction of *Dr. Maxwell Finland, (founder of subspecialty infectious diseases).

Also awarded a 1-year fellowship in molecular biology under the direction of **Dr. James Darnell, Massachusetts Institute of Technology, Cambridge Massachusetts.

Chief of the Division of Infectious Diseases and Professor of Internal Medicine at Wayne State University School of Medicine, 1963-1982.

Chief of the Department of Medicine at Hutzel Hospital, Wayne State University, Detroit, MI 1970-1982.

Established a clinical virology laboratory and trained 33 physicians in the subspecialty of infectious diseases, Wayne State University, 1963-1982.

Elected member American Society for Clinical Investigation, American Association of Physicians.

Member of the committee preparing the National Boards in Medical Examiners, US.

Member of the training grant committee, National Institute of Allergy and Infectious Diseases, NIH.

Master of the American College of Physicians.

Governor for Michigan American College of Physicians, 1991-1994.

Member of the attending staff at William Beaumont Hospital, Royal Oak, MI, 1963.

Holds Five Patents for Diagnosis and Treatment of CFS.

Honorary Master of the American College of Physicians.

 

[Waverunner]

Here's the scienedaily article:

http://www.sciencedaily.com/releases/2012/11/121114171708.htm

...In these six patients, the study suggests that a latent Epstein-Barr virus had begun to reactivate, but that the newly awakened virus never reached its full potential to take over its host cells. That partial reactivation advanced enough to generate at least two viral proteins, DNA polymerase and dUTPase, and these patients produced antibodies specifically designed to identify and neutralize those proteins for more than a year.
The scientists theorize that even in the absence of a complete active infection, these viral proteins' ability to induce inflammatory chemical signals causes enough immune system chaos to lead to CFS. The disorder's main symptom is profound fatigue for at least six months that does not improve with rest, and is accompanied by problems that can include weakness, muscle pain, impaired memory and depression. Because the illness mimics many other disorders, diagnosis is difficult. An estimated 1 million Americans have CFS, but experts believe only 20 percent are diagnosed....

 

[Firestormm]

Here's the scienedaily article:

http://www.sciencedaily.com/releases/2012/11/121114171708.htm

...In these six patients, the study suggests that a latent Epstein-Barr virus had begun to reactivate, but that the newly awakened virus never reached its full potential to take over its host cells. That partial reactivation advanced enough to generate at least two viral proteins, DNA polymerase and dUTPase, and these patients produced antibodies specifically designed to identify and neutralize those proteins for more than a year.
The scientists theorize that even in the absence of a complete active infection, these viral proteins' ability to induce inflammatory chemical signals causes enough immune system chaos to lead to CFS. The disorder's main symptom is profound fatigue for at least six months that does not improve with rest, and is accompanied by problems that can include weakness, muscle pain, impaired memory and depression. Because the illness mimics many other disorders, diagnosis is difficult. An estimated 1 million Americans have CFS, but experts believe only 20 percent are diagnosed....

The fact that CFS patients experience different symptoms and multiple types of viral and bacterial infections has led researchers to believe CFS potentially has numerous causes. That lack of uniformity also complicates the diagnostic process and development of treatments.

"Part of the problem in trying to identify an agent or biomarkers for chronic fatigue syndrome is the extreme variability among people who say they have CFS. How to sort that out has held the field back a lot of years," said Glaser, who has studied the Epstein-Barr virus (EBV) for decades.

...

"Every one of the six had antibodies to DNA polymerase or EBV dUTPase and those antibodies persisted over some 408 days," Lerner said. "And the antibody levels were extraordinarily high." High levels of antibodies circulating in the blood suggest long-term immune activation against those proteins.

Williams noted that the levels might be less significant than the antibodies being present in the first place.
"If you look at most healthy individuals, they wouldn't have any reason to have an antibody against either of these proteins," he said. "The antibodies alone are a good differentiator."

It was a small study, and a far larger one is needed of course, blinded obviously, as the authors themselves admit. Still, it is promising, if only for a subset of patients.

Opens up the debate once again for subsets of similar patients with 'CFS' who arrived at the diagnosis by way of known viral infection.

If he has found such antibodies to be causal for the symptoms and level of disability (big if?) reported by those diagnosed with CFS and this hypothesis can be validated, then extended, replicated for other viral causes - well then the ball is back in the court. Again.

Fascinating discovery. Cautionary tale.

 

[nanonug]

...In these six patients

Six patients? It's not possible to draw any conclusions from a sample this small.

 

[AFCFS]

I have mentioned this elsewhere, but one of the guys who wrote that article, A. Martin Lerner, has a pretty interesting and informative website/practice: The Treatment Center for Chronic Fatigue Syndrome (CFS).

There are two long videos there that are pretty in depth, as well as other information on the site. What I don't get is this guy seems exceedingly qualified (see physician profile below), but in the videos there are just a handful of people in the audience. He looks to be getting up there in years, but think the videos are worth watching if someone has an interest in this route of research/practice.

CFS Publications - has more studies. Think in the one they have 106 in this study:

An update on the management of glandular fever (infectious mononucleosis) and its sequelae caused by Epstein–Barr virus (HHV-4): new and emerging treatment strategies. Virus Adaptation and Treatment 2010:2 135-145

Beginning in 1993 at a single chronic fatigue syndrome (CFS) treatment center, we began studies that demonstrate Epstein–Barr virus (EBV) nonpermissive replication. In the mostrecent study performed, EBV nonpermissive replication is the cause of 28.3% of 106 consecutive CFS cases, and is etiologic with human cytomegalovirus (HCMV) and/or human herpes virus 6 (HHV-6) as a coinfection in an additional 52.8% of CFS cases. Therefore, EBV is causally involved in 81% of cases of CFS. Further, EBV CFS is effectively treated with long-term valacyclovir. Coinfection HCMV and HHV-6 CFS requires valganciclovir with valacyclovir. The validated Energy Index Point ScoreR (EIPSR) monitors severity of CFS illness and its recovery. A specific CFS diagnostic panel identifies EBV CFS subsets. Four separate EBV CFS therapeutic studies of several hundred CFS patients describe valacyclovir administration and long-term patient recovery. With valacyclovir, serum EBV titers (EBV, early antigen (diffuse); EBV, viral capsid antigen, immunoglobulin M); 24-hour electrocardiography Holter monitors; and cardiac dynamic studies improve. In conclusion, nonpermissive EBV infection is causal in a significant proportion of CFS cases. EBV CFS is safely and effectively treated with long-term valacyclovir.

Think if you go through the videos (the 2nd one at about minute 55 on) he talks a lot about percent of positive outcomes and then possible relapse rate. At around minute 68-69 he talks about how the protocol is essentially maligned by most infectious disease specialists - this is the story of basically anything new (he says something of similar effect).

 

[Waverunner]

Six patients? It's not possible to draw any conclusions from a sample this small.

That's what I thought, too. If CFS wasn't that much of a funding desert, we would see a lot more studies with a lot more patients.

 

[Firestormm]

EBV has been looked at so hard before now, I am surprised this hasn't come to light previously. Have to wait and see. Assuming of course this is followed up on....

 

[Esther12]

More research needed? It's my favourite conclusion!

 

[snowathlete]

Small study, but it's still very promising.
I hope a larger replication study gets done, but frustratingly other promising studies that Lerner and others have done before on EBV havent been followed up by anyone. No funding.

Surely there must be other information held by doctors treating ME/CFS patients that would match this finding (if correct) though, no?
Or are some of these EBV protein antibodies not usually tested, even by ME/CFS docs?

In my case, the only serious illness i ever had before ME/CFS was mono and i had it very severely. Never felt 100% after that. I've always felt that was a real possibility for causing my ME. The only other thing i know about is that i had some vaccines not long before i got ME. Could be either, or both, or none of them.

 

[alex3619]

Six patients is on the order of a pilot study. To be even close to robust hundreds are needed. A pilot study can be used to show the potential of a research proposal, and become justification for a larger study. Replication of the results, preferably by an independent team, can then lead to funding a really statistically significant study. At that point, presuming the study confirms the results, it becomes difficult to refute without good evidence or analysis to show that something is wrong. It is so very hard to get funding, every research evenue has to start somewhere.

 

[alice]

Source: Ohio State University
Date: November 14, 2012
Auteur: Emily Caldwell <caldwell.151@osu.edu>
URL: http://researchnews.osu.edu/archive/chronfatigue.htm


Discovery could lead to faster diagnosis for some Chronic Fatigue
Syndrome cases
-----------------------------------------------------------------

COLUMBUS, Ohio - For the first time, researchers have landed on a
potential diagnostic method to identify at least a subset of patients
with chronic fatigue syndrome (CFS), a complex disorder with no known
definitive cause or cure.

In a pilot study of six patients, scientists detected specific
antibodies linked to latent Epstein-Barr virus reactivation in blood
samples from people who had experienced classic CFS symptoms and
responded to antiviral treatment. Control blood samples from 20
healthy people showed no such antibodies.

The research team, led by scientists from Ohio State University and
Oakland University William Beaumont School of Medicine, acknowledges
that the number of patients is small. But the researchers say the
study's power rests in their access to 16 months of blood samples for
each patient - a collection allowing for an unprecedented longitudinal
look at CFS.

The researchers plan to move forward with development of a clinical
laboratory test that can detect these antibodies in blood samples.

The study is published in the Nov. 14 issue of the journal PLOS ONE.

The Epstein-Barr virus is a human herpes virus that causes infectious
mononucleosis and several different types of tumors. An estimated 95
percent of Americans have been infected with the virus by adulthood,
according to the Centers for Disease Control and Prevention (CDC), but
fewer than half have experienced an active illness. Once a person is
infected, the virus remains dormant in the body, and can be
reactivated without causing symptoms of illness.

In these six patients, the study suggests that a latent Epstein-Barr
virus had begun to reactivate, but that the newly awakened virus never
reached its full potential to take over its host cells. That partial
reactivation advanced enough to generate at least two viral proteins,
DNA polymerase and dUTPase, and these patients produced antibodies
specifically designed to identify and neutralize those proteins for
more than a year.

The scientists theorize that even in the absence of a complete active
infection, these viral proteins' ability to induce inflammatory
chemical signals causes enough immune system chaos to lead to CFS. The
disorder's main symptom is profound fatigue for at least six months
that does not improve with rest, and is accompanied by problems that
can include weakness, muscle pain, impaired memory and depression.
Because the illness mimics many other disorders, diagnosis is
difficult. An estimated 1 million Americans have CFS, but experts
believe only 20 percent are diagnosed.

The study's senior researchers agree that the work should be repeated
in more patients 'to confirm that these observations are real,' said
virologist Ron Glaser, director of the Institute for Behavioral
Medicine Research at Ohio State and a co-author of the study. 'But
finally, after more than 20 years, this is at least something to go on.'

Glaser's primary collaborators on this work are Marshall Williams,
professor of molecular virology, immunology and medical genetics at
Ohio State, and A. Martin Lerner, a professor of internal medicine at
Oakland University William Beaumont School of Medicine.

Ohio State and Lerner's private practice, CFS LLC, have applied for a
patent for the diagnostic method.

Glaser and Williams first published a paper in 1988 suggesting that
these two viral proteins associated with partially reactivated
Epstein-Barr virus could function as biomarkers for certain illnesses,
including CFS. Meanwhile, Lerner became severely ill in 1986 and
struggled for 10 years with CFS symptoms before treatment with
antivirals dramatically improved his health.

Lerner, an infectious diseases specialist, runs his private CFS
practice in Michigan, and his long-term tracking of patients'
characteristics and response to treatment made this longitudinal
research possible.

The fact that CFS patients experience different symptoms and multiple
types of viral and bacterial infections has led researchers to believe
CFS potentially has numerous causes. That lack of uniformity also
complicates the diagnostic process and development of treatments.

'Part of the problem in trying to identify an agent or biomarkers for
chronic fatigue syndrome is the extreme variability among people who
say they have CFS. How to sort that out has held the field back a lot
of years,' said Glaser, who has studied the Epstein-Barr virus (EBV)
for decades.

Lerner had long ago separated 142 of his patients into two groups:
those who had tested positive for various antibodies against three
types of herpes viruses and responded to months-long treatment with
one of two types of antivirals, and a smaller group that had viral
infections and a variety of co-infections who showed minimal response
to antiviral treatment. As part of this tracking, he collected
multiple blood serum samples for more than a year from each patient.

From those patients, he selected blood samples from six for this
study. Five had been identified as an Epstein-Barr virus subset, and
the sixth had Epstein-Barr virus and a bacterial co-infection. For
comparison, researchers collected samples from 20 healthy people
matched to the six CFS patients for age and sex.

Lerner, too, had independently hypothesized that CFS patients might be
experiencing partial virus reactivation. Patients might test negative
for the most active antibodies required to fight a virus, but could
still recover from CFS after long-term antiviral treatment. One
antiviral he uses is known to inhibit DNA polymerase, which would halt
Epstein-Barr virus reactivation in its tracks.

With the CFS patients' and control blood samples in hand, Williams
used a highly sensitive laboratory method to detect whether they
contained antibodies to the two target Epstein-Barr viral proteins,
DNA polymerase and dUTPase, that are produced early in the process of
viral reactivation.

Overall, 78.8 percent of the serum samples from the six CFS patients
were positive for antibodies against DNA polymerase and 44.2 percent
were positive for antibodies against dUTPase. No antibodies to these
two proteins were detected in the 20 control samples.

'Every one of the six had antibodies to DNA polymerase or EBV dUTPase
and those antibodies persisted over some 408 days,' Lerner said. 'And
the antibody levels were extraordinarily high.' High levels of
antibodies circulating in the blood suggest long-term immune
activation against those proteins.

Williams noted that the levels might be less significant than the
antibodies being present in the first place.

'If you look at most healthy individuals, they wouldn't have any
reason to have an antibody against either of these proteins,' he said.
'The antibodies alone are a good differentiator.'

This work was partially supported by the National Institutes of Health.

Additional co-authors include Maria Ariza of the Department of
Molecular Virology, Immunology and Medical Genetics and Stanley
Lemeshow, dean of the College of Public Health, both at Ohio State;
Leonard Jason of DePaul University; Safedin Beqaj of Pathology Inc.,
in Torrance, Calif.; and James Fitzgerald of the University of
Michigan School of Medicine.


Contacts:

Ron Glaser, Ron Glaser, (614) 293-0178; Ronald.Glaser@osumc.edu
Marshall Williams, (614) 293-6175; Williams.70@osu.edu
A. Martin Lerner, (248) 540-9866; amartinlerner@yahoo.com

 

[HowToEscape?]

More research needed? It's my favourite conclusion!

Yeah, it's tempting to hear that. In our case it's correct --- there's really not enough.

It's also, in my poorly informed opinion, a characteristic of medical research. People, diseases and observations are all variable and the effects being observed are often modest, so teasing out what's actually going on requires studying the same thing multiple times. One study, even if done by competent people with good intentions, is often not enough to for confidence. I got that from a blog called "respectful insolence" which is mainly a cancer surgeon's take-down of quackery, but occasionally touches on other issues.

 

[Sushi]

...Surely there must be other information held by doctors treating ME/CFS patients that would match this finding (if correct) though, no?
Or are some of these EBV protein antibodies not usually tested, even by ME/CFS docs?
...

I have been tested for reactivated EBV a number of times, and have always tested positive for this. So, yes, some doctors have been, and still are testing this.

Sushi

 

[AFCFS]

I have been tested for reactivated EBV a number of times, and have always tested positive for this. So, yes, some doctors have been, and still are testing this.
Sushi

Is testing for reactivation of EBV the same as the "standard" EBV Antibodies Test?

From Lab Tests Online: Epstein-Barr Virus Antibodies

 

[Sushi]

Is testing for reactivation of EBV the same as the "standard" EBV Antibodies Test?

From Lab Tests Online: Epstein-Barr Virus Antibodies

View attachment 4141

Guess not because my test says "reactivated EBV"

Sushi

 

[AFCFS]

Is testing for reactivation of EBV the same as the "standard" EBV Antibodies Test?

From Lab Tests Online: Epstein-Barr Virus Antibodies

View attachment 4141

So it looks like only the DNA polymerase and dUTPase testing can detect the "sub clinical" reactivation? The CDC article, Epstein-Barr Virus and Infectious Mononucleosis, seems to claim it may be detectible with the "standard" EBV Antibodies Test (with an experienced physician). But I do not get what the "trick" is:

Finally, even when EBV antibody tests, such as the early antigen test, suggest that reactivated infection is present, this result does not necessarily indicate that a patient's current medical condition is caused by EBV infection. A number of healthy people with no symptoms have antibodies to the EBV early antigen for years after their initial EBV infection.

Therefore, interpretation of laboratory results is somewhat complex and should be left to physicians who are familiar with EBV testing and who have access to the entire clinical picture of a person. To determine if EBV infection is associated with a current illness, consult with an experienced physician.

Then they say this:

Additional Information about EBV Antibody Tests and Interpretation
Antibody tests for EBV can measure the presence and/or the concentration of at least six specific EBV antibodies. By evaluating the results of these different tests, the stage of EBV infection can be determined. However, these tests are expensive and not usually needed for the diagnosis of infectious mononucleosis.

So - with at least six specific EBV antibodies - are they then referring to the DNA polymerase and dUTPase testing or some other test(s)?

 

[snowathlete]

Then they say this:

Additional Information about EBV Antibody Tests and Interpretation
Antibody tests for EBV can measure the presence and/or the concentration of at least six specific EBV antibodies. By evaluating the results of these different tests, the stage of EBV infection can be determined. However, these tests are expensive and not usually needed for the diagnosis of infectious mononucleosis.

So - with at least six specific EBV antibodies - are they then referring to the DNA polymerase and dUTPase testing or some other test(s)?

I dont know but i would like to. Hopefully, someone else who knows will chime in to inform us.

Also, why do we need six different antibodies, for one virus? (this is probably a junior question, but thats where im at)

 

[Sushi]

I dont know but i would like to. Hopefully, someone else who knows will chime in to inform us.

Also, why do we need six different antibodies, for one virus? (this is probably a junior question, but thats where im at)

I think that the different antibody tests are to try to gauge the different stages of viral activity/infection. I'd have to dig through old tests to see how they named all the different antibody tests. I don't have time at the moment, but if I find them, I'll post it. My last one didn't give the details, just said "Reactivated EBV."

Sushi

 

[snowathlete]

It looks like this study of six people, probably came out of this larger study by Lerner, also recently published:
http://www.dovepress.com/abortive-l...-tonsil-b-lymphocy-peer-reviewed-article-VAAT

That explains the low number of people in the study.

Published Date November 2012
A Martin Lerner,1 Safedin Beqaj2
1Department of Medicine, Oakland University William Beaumont School of Medicine, Rochester, MI, USA; 2Pathology Inc, Torrance, CA, USA

Abstract: A systematic 2001–2007 review of 142 chronic fatigue syndrome (CFS) patients identified 106 CFS patients with elevated serum IgG antibodies to the herpesviruses Epstein–Barr virus (EBV), cytomegalovirus, or human herpesvirus (HHV) 6 in single or multiple infections, with no other co-infections detected. We named these 106 patients group-A CFS. Eighty-six of these 106 group-A CFS patients (81%) had elevated EBV early antibody, early antigen (diffuse), serum titers. A small group of six patients in the group-A EBV subset of CFS, additionally, had repetitive elevated-serum titers of antibody to the early lytic replication-encoded proteins, EBV dUTPase, and EBV DNA polymerase. The presence of these serum antibodies to EBV dUTPase and EBV DNA polymerase indicated EBV abortive lytic replication in these 6 CFS patients. None of 20 random control people (age- and sex-matched, with blood drawn at a commercial laboratory) had elevated serum titers of antibody to EBV dUTPase or EBV DNA polymerase (P < 0.01). This finding needs verification in a larger group of EBV CFS subset patients, but if corroborated, it may represent a molecular marker for diagnosing the EBV subset of CFS. We review evidence that EBV abortive lytic replication with unassembled viral proteins in the blood may be the same in infectious mononucleosis (IM) and a subset of CFS. EBV-abortive lytic replication in tonsil plasma cells is dominant in IM. No complete lytic virion is in the blood of IM or CFS patients. Complications of CFS and IM include cardiomyopathy and encephalopathy. Circulating abortive lytic-encoded EBV proteins (eg, EBV dUTPase, EBV DNA polymerase, and others) may be common to IM and CFS. The intensity and duration of the circulating EBV-encoded proteins might differentiate the IM and EBV subsets of CFS. Abortive lytic replication may be a pathogenic mechanism for EBV disease. EBV (HHV4) is a gamma herpesvirus composed of dsDNA about 170 Kb in length. For this discussion, there are early genes (including expressions of encoded proteins EBV dUTPase, DNA polymerase, and nuclear proteins) and late genes (including expressions of capsid and membrane proteins). Abortive infection infers incomplete virion expressions of either early or late proteins, but the virion is incomplete. The lytic virus infers a complete virion. The pathologic consequences of EBV abortive replication are currently being investigated by authors.