Innate Immune Changes in the Peripheral Blood

[Kati]

Has bone marrow transplant actually been trialled in RA and lupus then?

@Bob I believe the old technology forced physicians to harvest marrow from the hip. So the 'transplant' would be really a bone marrow transplant.

Now with new technology, patients go in, and through an IV blood donation. Stem cells are being extracted while other blood cells remain with the patient. i haven't seen a cell separator myself, and how exactly it works, but this is how they do it for the most part these days. Especially for those doing the autologous procedure.

 

[Bob]

@Kati, thank you. I'm interested in the procedure of depleting the immune system and resetting it with stem cells, but I don't know the precise term for this. I didn't know that it had been tested on such diseases as RA and lupus because I thought it was too dangerous a procedure to be used on anyone without an imminently life-threatening disease.

Wikipedia links to a 1999 article that suggests it had been trialled quite widely on autoimmune illnesses but with a high mortality rate at that time:
http://www.nature.com/bmt/journal/v24/n7/abs/1701987a.html

I'll have a look to see if I can find more recent literature.

Edit: Here's a helpful overview (of stem cell transplants for autoimmune disease) from 2011:
http://www.ncbi.nlm.nih.gov/pubmed/22160046

 

[Jonathan Edwards]

Has bone marrow transplant actually been trialled in RA and lupus then?

Oh yes, Alan Tyndall did a substantial RA series in Switzerland and Anne Traynor has being doing it in lupus for some years with considerable success. It has also been used for scleroderma, vasculitis and some childhood autoimmune syndromes. It can work very well for a while but the problem is that it is not that much better than rituximab for RA and it is much more risky.

 

[Snow Leopard]

A number of studies have found low or abnormal cortisol secretion in ME. What measure(s) did Stuart Watson go by?

I did an extensive review a while back and my opinion is that studies measuring (just) cortisol in these case/control studies are mostly worthless.

Disruption to cortisol cycles can occur due to disrupted sleep, but other factors such as simply leading a housebound lifestyle can lead to lower stress and thus subtly alter day to day cortisol levels. Without testing the other aspects of the system at the same time (the receptor activity or expression levels for a start), it is impossible to get much of a picture of what is going on.

ACTH or CRH induced cortisol responses, along with dexamethone supression testing have been all over the park. Likewise, investigations of glucocorticoid receptor expression, density or dexamathesone suppression testing has been inconsistent. There is perhaps a link towards reduced vasopressin, which would also potentially explain the OI issues.

My overall conclusion was that any subtle disruptions in the HPA axis were not of primary importance and were a consequence of something else.

 

[Snow Leopard]

Even the NK findings are inconsistent. The one UK group I know that has studied this found no abnormality.Of the people who found abnormalities some found changes in numbers and others did not but found changes in killing assay activity.

The NK cell numbers are inconsistent, but low NK cell activity has been noted in a large majority of studies, (we're talking 20+ studies by now, this is one of the most replicated findings so far.).

The problem is that the finding itself isn't particularly exciting and may simply reflect a lower level of activity of CFS patients vs controls (in my opinion anyway).

 

[duncan]

Snow Leopard, why isn't the low NK cell activity exciting? I do not mean to hijack this thread, but what IS the relevance of a low NK cell value? I ask because I will be soon visiting the NIH, I have a low out-of-range value, and I intend to throw this value at, um, them.

What will be their response? Will they simply shrug it off?

 

[Jonathan Edwards]

Thanks, Snow Leopard. While I had come to the same conclusions I am sure you have done the homework more thoroughly than I have. There is clearly a likelihood that an apparent tendency to low cortisol is secondary to activity and sleep changes.

As to the NK cells, of interest to Duncan, I again agree that there seems to be some degree of consistency but low NK cell values have, in immunology, become one of those things people tend not to give much significance to. Very low values can turn up in diseases without any obvious significance. And since the discovery of the complexity of NK KIR receptors it has become clear that we have little or no way of interpreting even the results we have.

On a broader front, to answer Duncan, numbers of cells in the blood are probably not of huge importance unless they are hugely high (as in leukaemia) or very low (as in agranulocytosis or AIDS). Lymphoid cells in blood are simply trafficking through. You might say that there are more people in London than New York because Londoners walk on the pavement(sidewalk) more than Americans and Oxford Street is jam solid with bodies. But it is just a traffic pattern. Inflammation tends to be associated with a raised neutrophil count but anti-inflammatory steroids also raise the neutrophil count - because they make them lazy about trafficking OUT of blood. Low NK cell numbers might mean the NK cells are very busy trafficking to tissues out of the blood.

The bottom line, I think, is that immunologists outside the ME field will more or less unanimously say that the 'low values' found in ME are not anything they would get excited about.

 

[Marco]

The NK cell numbers are inconsistent, but low NK cell activity has been noted in a large majority of studies, (we're talking 20+ studies by now, this is one of the most replicated findings so far.).

The problem is that the finding itself isn't particularly exciting and may simply reflect a lower level of activity of CFS patients vs controls (in my opinion anyway).

I came to the same conclusion :

NK cell cytotoxicity

Oxidative stress alone, in conditions such as type II diabetes and renal failure (Berrou et al, 2013) may also account for reduced NK cell cytotoxicity through dysfunction or apoptosis of NK cells (Betten et al, 2004; Wang et al, 2009).

However one NK cell finding requires further explanation. Brenu (Brenu et al, 2012) reported that “significantly lower numbers of CD56brightCD16- NK cells” may lead to a greater susceptibility to viral and other infections and may be a ‘biomarker’. CD56(bright) NK cells make up a minority of NK cell types but represent the majority in lymphatic tissues and are associated with sites of inflammation (Chan et al, 2007). While the exact proportion of these cells varies, the percentages are expanded or reduced in a certain number of diseases including coronary heart disease, allergic rhinitis and juvenile rheumatoid arthritis (Brenu et al, 2012). While, the significance of these variations is not yet clear (Poli et al, 2009), their presence does suggest that ME/CFS fits in a broad realm of inflammatory disorders.

Autoimmunity

In the context of a possible autoimmune etiology of ME/CFS discussed in Part II, it’s notable that CD56 bright NK cell counts discussed above may be used to determine how effective the monoclonal antibody daclizumab is in the treatment of relapsing/remitting multiple sclerosis (RRMS). This supports the immunomodulatory role natural killer cells play in reducing brain inflammation and slowing disease progression in RRMS. (Bielekova et al, 2006) :

“daclizumab therapy was associated with a gradual decline in circulating CD4+ and CD8+ T cells and significant expansion of CD56 bright natural killer (NK) cells in vivo, and this effect correlated highly with the treatment response”

This suggests that the low levels of CD56 bright natural killer (NK) cells seen in ME/CFS could reflect similar ‘brain inflammation’ and a possible autoimmune etiology.

The latter of course could well just be coincidence.

 

[duncan]

Thank you, Dr. Edwards. If out-of-range NK cells values, whether low or high, are not given much significance to, then:
a) Why the interest in the first place?
b) Why do labs offer the test?.
c) How does one turn their back on out-of-range values, when by definition they are anomalies?

Some groups clearly have demonstrated a strong association between low NK cell activity and ME/CFS and high viral titers. Are we then to conclude or infer those associations are frivolous?

More to the point, what are immunologists actually taught the implications of low - or high - NK cell signify? Is this not part of an immunologist's curriculum? And to where should I refer that insulated immunologist outside the ME/CFS theater that is simply ignorant? Because I'd wager a goodly amount that I will encounter them in my "field trip" to Bethesda.

Incidentally, you also will see low CD56bright NK cells in Lyme arthritis, as well as the well known Low CD 57 counts frequently used by LLMDs diagnostically.

 

[liquid sky]

I do wish someone would get excited about something. The innate immune system needs a closer look in ME. Some follow up studies on the SFFV antibodies are warranted. It could be a new autoantibody that helps to break this decades old puzzle.

When you look at what finding the autoantibody means to a disease, it is obvious how crucial it is to understanding the disease. Most autoimmune diseases are diagnosed on auto-antibodies, RA factor, ANA(various), anti-MUSK, etc. This can lead to a target for treatment, which is what we all want. There has already been a sub-group of PwME that have an elevated ANA. These things need to be followed up on, not ignored.

 

[Jonathan Edwards]

Thank you, Dr. Edwards. If out-of-range NK cells values, whether low or high, are not given much significance to, then:
a) Why the interest in the first place?
b) Why do labs offer the test?.
c) How does one turn their back on out-of-range values, when by definition they are anomalies?

Some groups clearly have demonstrated a strong association between low NK cell activity and ME/CFS and high viral titers. Are we then to conclude or infer those associations are frivolous?

More to the point, what are immunologists actually taught the implications of low - or high - NK cell signify? Is this not part of an immunologist's curriculum? And to where should I refer that insulated immunologist outside the ME/CFS theater that is simply ignorant? Because I'd wager a goodly amount that I will encounter them in my "field trip" to Bethesda.

Incidentally, you also will see low CD56bright NK cells in Lyme arthritis, as well as the well known Low CD 57 counts frequently used by LLMDs diagnostically.

a) Good question
b) Good question - but the answer is because doctors ask for them and pay (with the patient's money).
c) These values may be statistical anomalies but, as indicted in the response to Sash, that does not make them biological anomalies. Red hair falls outside 95% of the human population but is not an 'anomaly'. NK cells are weird in that they have a bewildering variety of receptors that switch them on and off and not only do different people have different versions, it seems to be a toss up whether any one person has both a receptor and the MHC ligand that it should bind to. It seems that some people are born with a gene for the receptor but no gene for anything for it to bind to. Basically we have no idea (at least last time I was a t a lecture) what is going on here. It is perfectly possible that people with low numbers of cells have low numbers because their cells are so good at killing that the feedback mechanism runs the system on low numbers. When we know just how complicated the genetics are we have no way of knowing how complicated the rules for 'adequate numbers' should be, I think.

I would not say that the observations on low NK numbers or activity and ME and viral titres are 'frivolous'. It is just that they do not seem to be consistently reproducible. Sadly, most of biomedical science observations turn out to be unreproducible and are thrown in the bin. The reasons for this are very complex but probably have to do with the muddled way all humans think and work.

Last time I was talking with immunology colleagues the consensus was that NK values are pretty uninterpretable most of the time unless they are completely defective. The is, as far as I know, what would get taught to post grad students in an immunology department. I don't actually think the immunologists outside the ME field are ignorant. I think they may be less blinkered to be frank! And within the ME field, as going by the international meetings of researchers I have recently attended I would say that by and large the consensus is with the unblinkered lot.

 

[duncan]

"...muddled way all humans think and work."

Naturally, in this context muddled is euphemistic for...?

Thank you for your comprehensive handling of my multiple questions. When I go to the NIH I will plan on bluffing my way through when it comes to NK cell values, and blindly hoping I encounter no immunologists. The Infectious Disease crowd - those folks I can hold my own with. Maybe.

 

[Jonathan Edwards]

"...muddled way all humans think and work."

Naturally, in this context muddled is euphemistic for...?

Thank you for your comprehensive handling of my multiple questions. When I go to the NIH I will plan on bluffing my way through when it comes to NK cell values, and blindly hoping I encounter no immunologists. The Infectious Disease crowd - those folks I can hold my own with. Maybe.

Muddled is not a euphemism for anything - it is a recognition of the intellectual frailty that none of us can avoid. The human mind is designed to latch on to things in the hope they are important. Even after years of moderation with self-discipline the instinct shows through. Nobody is to blame here - we just need to be a bit humble I think.

 

[Jonathan Edwards]

I do wish someone would get excited about something. The innate immune system needs a closer look in ME. Some follow up studies on the SFFV antibodies are warranted. It could be a new autoantibody that helps to break this decades old puzzle.

When you look at what finding the autoantibody means to a disease, it is obvious how crucial it is to understanding the disease. Most autoimmune diseases are diagnosed on auto-antibodies, RA factor, ANA(various), anti-MUSK, etc. This can lead to a target for treatment, which is what we all want. There has already been a sub-group of PwME that have an elevated ANA. These things need to be followed up on, not ignored.

I hope that we are not giving the impression that nobody is excited about anything. I am excited about all sorts of possibilities. I have just been around long enough not to put too much money on a horse before I have seen it run. Science is all about killing 95% of the ideas around so that you can focus on the 5% that might be right. That can seem negative but it is the only way that works and when you find an idea that might work and then discover it works in ten times as many situations as you expected it is all worth it. Just at the moment ME research needs a killing off of an awful lot of stale ideas because there are far too many around for them all to be right. Anyone who is emotionally attached to these ideas has to realise that science does not do emotional attachment to ideas. That does not mean that you are not allowed to paint the town red when you finally get something worth publishing in the New England Journal of Medicine.

 

[Kati]

It is discouraging that 30 years of abysmal funding and so few researchers lead us where we are and we are still muddling through thick fog. It is discouraging that our governments have no will to research this disease. It is discouraging that pharma has no interest whatsoever. And now with Ebola, gvernments and pharma will go on their merry way in finding treatment for Ebola, and then they're not done with HIV. It is so frustrating to be left behind and to be told that the tests that we are paying from our pocket (and they are expensive) are insignificant.

Dysfunctional NK cells is a feature that is very much present in ME. I believe Sonya Marshall-Gradisnik could correlate with severity of illness.

Patients (and i will speak for most of us) want proof of illness on paper. Because no one believes us including drs, employers, insurance companies and family members. Surely, in 2014, there is a way to find a biomarker for this disease, and the capacity to have a case definition with defined subsets?

30 years since Incline Village and Lyndonville, NY epidemics. 80 years since the 1934 Royal free epidemics.

 

[Jonathan Edwards]

It is because of the sentiments you express, Kati, that I feel I cannot leave this alone. Even if at times it seems like the Rubic cube - which I could never do. So what biomarker? The chain of posts sets me thinking. So if NK values are just showing traffic what about the numbers of cells in lymph nodes? Do people with ME have more cells in their lymph nodes, or less? Sounds to me as if maybe at least some have more - tender swollen lymph nodes is even in the criteria I think. More lymphocytes in nodes, or gut lymphoid tissue would be a start - and a bit more solid than traffic.

You cannot get at lymph nodes to count cells as such - we have tried with needle biopsies and it is no good for this sort of situation. But I just wonder if anyone has ever done Gallium scans or something similar in ME? Gallium might not be the right tracer but something like that might show up. It would not need to be specific - just to confirm that there really is something going on there. PubMed shows zero hits on Gallium and CFS but maybe someone knowledgeable on the list knows more?

 

[duncan]

"...we just need to be a bit humble, I think."

Yeah, well, nobody I know would ever accuse the lion's share of clinicians and/or researchers as being a humble lot. Lots of adjectives leap to mind, but humble isn't one, at least not for many of that group. Neither does "intellectual frailty". Certainly the individuals who take a pass on doing follow-up confirmatory studies of the relevance of NK cell activity levels to ME/CFS, or worse, toss such efforts in the bin, don't deserve to seek refuge under "intellectual frailty"; I suspect their actions are often intelligent and deliberate - just wrong.

And I was kidding about the euphemism thing. I should have made that clearer. My bad.

 

[Kati]

This may be off topic a bit but in continuation with the conversation on biomarkers.
i live by myself but my father is in town this week. i don't talk much when i'm on my own, I don't talk on the phone much. so this week i've done a whole lot more talking than I usually do.

Talking hurts my head a lot. It feels to me like brain inflamation. i really wish biomarkers would show that. A brain scan even.
My dad left to see my other sister for a couple of days, and as he came back the same pain in my head. Talking is making me feel horrible.

I hear Dr Baraniuk is doing functional MRI studies before and after exercise.

Gallium, I don't think i had. But I received technicium for a full body bone scan. Nothing much of interest came up but this curious bright uptake on my left upper chest. Perhaps one broken rib from a bike fall from 2007. Apparently the uptake on all my achy joints were normal, but thankfully there was also uptake on my left ankle osteochondral cyst, which definitely is not in my head. (It took 3 long years to determine it was not in my head )

 

[Jonathan Edwards]

Technetium would not show lymphocytes. I guess some clever PET reagent might be better than Gallium, which probably shows mostly macrophages. The Japanese PET study this year might be something to get excited about and I am hoping it will be repeated. And Baraniuk's pictures of altered pathways in brain are also very interesting.

 

[WillowJ]

On a broader front, to answer Duncan, numbers of cells in the blood are probably not of huge importance unless they are hugely high (as in leukaemia) or very low (as in agranulocytosis or AIDS). Lymphoid cells in blood are simply trafficking through. You might say that there are more people in London than New York because Londoners walk on the pavement(sidewalk) more than Americans and Oxford Street is jam solid with bodies. But it is just a traffic pattern. Inflammation tends to be associated with a raised neutrophil count but anti-inflammatory steroids also raise the neutrophil count - because they make them lazy about trafficking OUT of blood. Low NK cell numbers might mean the NK cells are very busy trafficking to tissues out of the blood.

In the absence of "exciting" markers, though, couldn't we use NKCC as a nonspecific marker for now, a lot like ANA is or has been used--doesn't mean a lot, particularly not anything highly specific, by itself, but could contribute to diagnosis? As a "this is a class of thing that is happening" kind of marker? (e.g. maybe it says there is inflammation?)