Transcript Treating Chronic Fatigue Syndrome (CFS) & Fibromyalgia (FM) by

Derek Enlander, MD
860 Fifth Avenue
New York, NY 10065 USA
1-212-794-2000
[email protected]
Treating Chronic Fatigue Syndrome
(CFS) & Fibromyalgia (FM) by
Targeting the Methylation Cycle
Basic cell process
O v e rv ie w o f b a sic ce ll p ro ce sse s
Pathogenisis
C h ro n ic F atig u e S y n d ro m e (C F S )
S tu d ies o f P ath o g en esis
Im m u n e sy stem -
 IC ’s,  Ig G ,  B cells,  N K
T h 2 p h en o ty p e
c y to k in e d y sreg u latio n / c h ro n ic im m u n e ac tiv atio n
In fec tio n -
v iru s, b acte riu m
N erv o u s sy stem -
p are sis, v isu al lo ss, atax ia, c o n fu sion
ab n o rm al m e tab o lism o f 5 -H IA A , A -V , 5 -H T , P R L
b rain sc an a b n o rm alitie s
E n d o crin e sy stem -
slig h t  H P A axis
C ard io v ascu lar sy stem -
v aso d ilatatio n
P sy ch o lo g ical fu n ctio n -
d ep ressio n & an xie ty
G en e tic p red isp o sitio n -
d ed u c ed fro m tw in stu d ies
Virus as Causative Agent
•CFS often starts with a flu-like episode
•CFS symptoms wax and wane
•Antiviral pathways are activated
•CFS symptoms are similar to many viral conditions including:
oEBV mononucleosis
oRoss River virus
•Geographic outbreaks have been reported
•Gene expression profiling found genetic variants that impact antiviral
defenses
•Antiviral treatments have been effective in in small studies
oAmpligen
oisoprinosine
obeta interferon
ovalganiclovir
Viruses Implicated In CFS
Human herpesviruses
EBV (HHV-4)
CMV (HHV-5)
HHV-6
HHV-7
Stealth Virus (Simian)
Enteroviruses
Polio
Coxsackie A & B
Echovirus
Foamy virus [spuma virus]
Parvo virus
B-19
Hepatitis-C virus
JHKV
Rubella virus
Ross River virus (RRV)
Inoue-Melnick virus
Borna virus
HERV
Human Endogenous
Retrovirus
HHV6 virus
•
Discovered in 1986 by Ablashi and
Salahuddin at NCI in patients with
lymphoproliferative disease( slide by kind
permission of Dharam Ablashi)
•
HHV-6 is an enveloped, double-stranded
DNA virus with an icosahedral capsid and
virion size of 160-200 nm. The genome
contains 70 proteins. Some of these
proteins (early antigen and immediate early
antigen) can be used to detect active
infections.
•
Two very distinct variants with 90%
nucleotide sequence homology. The genome
of variant A or B ranges from
159 – 170 kb.
•
Beta herpesvirus and genus roseola virus
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Over 90% of adults seropositive
•
Predominantly CD4 lymphotropic
HHV6
•HHV-6 has two variants, A and B. Each variant is associated with a subset of illnesses.
•HHV-6A infection comes later in life and has been linked to the pathogenesis of CFS,
rhomboencephalitis, and MS. It also plays a role in HIV, causing more immunosuppression
in AIDS patients.
•HHV-6B is the causative agent of Exanthem subitum, is strongly linked to infections in
transplant patients and is also associated with epilepsy and post-transplant acute limbic
encephalitis.
•HHV-6A is more lytic, and readily infects a variety of neural and other cells such as
astrocytes , and is also more neurotropic, leading to cognitive disorders in CFS and
MS patients.
•Both A & B strains cause encephalitis, amnesia, facial paralysis, chronic myelitis and
transverse myelitis.
•HHV-6A can lead to enhanced production of EBV, HSV and HHV-8. Both variants also
induce expression of human endogenous retrovirus K-18 encoded super antigen.
HHV6 (cont.)
•Both strains establish latency in monocytes, macrophages and target CD4 cells for
infection.
•Since HHV-6, like other human herpesviruses, is ubiquitous, its role in the
pathogenesis is established when the virus is in the active state of infection.
•Anti-viral agents foscarnet, cidofovir and ganciclovir inhibit CMV infection do not
block HHV-6 infection, especially of the A variant as efficiently.
HHV-6 infection contributes to immune suppression by:
•Disturbing key immune activation pathways and cytokine networks.
•Depleting CD4 T lymphocytes via direct infection and induction of apoptosis (Lusso)
•Upregulating TNF alpha, TNF- gamma, IL-1beta and IL-10.(Flamand, Dockerell, Li) and IL-21.
•Downregulating complement activity through the CD46 receptor
suppressing macrophages to produce IL-12 stimulated with gamma interferon.(Lusso 2004)
Localization of HHV-6 variants in myocardial tissue by IHC
Myocardial hhv6
HHV-6 B
HHV-6 A
Detection of interstitial cells
Kühl et al., 2008, submitted
www.ikdt.com
IHC Labeling of cardiomyocyte
Astrocytes obtained from lateral temporal lobe infected with HHV-6
Astrocyte hhv6
Infected astrocyte
Antiviral / immuno used for CFS
Antiviral
Study
ampligen
isoprinosine (Immunovir)
alpha 2a interferon
acyclovir (Zovirax)
valacyclvir (Valtrex)
valganciclovir (Valcyte)
valganciclovir (Valcyte)
Hepapressin, Immunoprop
Strayer 1994
Pinching 2002
See, 1996
Straus 1990 (5 weeks)
Lerner, 2001 (6 mos)
Lerner, 2006 (6 mos)
Montoya, 2006 (6 mos)
Enlander 2007 (12 mos)
effective?
yes ???
yes
yes ?
no
yes ??
yes
yes
yes
Methylation cycle
Reasons to Target Methylation Cycle
• Paul Cheney, M.D. reported “almost
universal” glutathione depletion in CFS in
1999
• Rich Van Konynenburg, Ph.D. reported that CFS
symptoms can be explained by glutathione
depletion [AACFS 7th Intl. Conf.]
• Personal experience with glutathione
supplementation and methylation targeting
Current Treatment part 1
 Hepapressin Complex
Weekly Injection
Hepapressin
Magnesium Sulphate
Folic Acid
B12
Calphosan
Glutathione
Trace elements
 Clinical trial 1994
 Kutapressin Derivative
 History of treatment
Current Treatment part 2
 BetaMax
 Methyl B12 Spray
Methyl Cobalamine
Vitamin B6
 Lectrolyte
Sodium
Potassium
Calcium
Magnesium
Trace Zinc
 Catapult
Picamilon
Cat’s Claw
Glutathione
L-cystine
Trace Selenium
 Provides energy
 Relieves muscle pain
 Clears Brain Fog
Current Treatment part 3
 Immunoprop
Glutathione
L-cystine
Picamilon/Ascorbic Acid?
Trace Selenium
 Immunoplus
Folinic Acid
Folic Acid
Vitamin B complex
Glutathione
L-cystine
Phosphadylserine
Trace Selenium
Trace Magnesium
Trace Zinc
Major Pathways - Methylation
Cycle
DHF
Diet
Choline
THF
Betaine TMG
Methyl Synthase (MS)
DNA, RNA
SAM
MAT (methionine
adenosyltransferase)
BHMT
B12
Zn
Methionine
Protein
synthesis,
Carnitine
SAH
Homocysteine
Zn, B6
Cystathionine
Glutathione
Main Role of Methylation Cycle
• Methyl Group Source for the body
• Coordinate sulfur metabolism
• Coordinate production of DNA
Methionine-Homocysteine
Pathway
Methionine
S-Adenosylmethionine
S-Adenosylhomocysteine
Homocysteine
B12, B6, Mg
Cysteine
Glutathione
Cystathionine
Toxic Sulphites
Sulphates
Role of Hepapressin Injection
Methionine
S-Adenosylmethionine
S-Adenosylhomocysteine
Folic Acid
Homocysteine
B12, B6, Mg
Cysteine
Glutathione
Cystathionine
Toxic Sulphites
Sulphates
Antiviral treatment
Hepapressin / Kutapressin / Nexavir
Bovine/Porcine
Phase
Liver Extract once weekly
I clinical trial 1994
Invivo
antiviral activity
Valganciclovir ..Valcyte 450mg twice daily
Montoya,
Case
2006
Study, Retinal Uveitis + CFS
Modest
Effect
Important
to identify appropriate CFS patient titer 1:640
Gene expression 2005
P ilo t
s tu d y
S tu d y o f G e n e E x p re s s io n in
C h ro n ic fa tig u e s y n d ro m e
P ilo t s tu d y - 2 0 0 5
H y p o th e s is : th a t a b n o rm a litie s o f g e n e r e g u la tio n o c c u r in C F S
2 5 C F S p a tie n ts & 2 5 n o rm a l c o n tr o ls
G e n e le v e ls d e te rm in e d b y M ic r o a r ra y a n a ly s is (9 ,5 2 2 g e n e s ) & re a l- tim e P C R
Kerr
collaborators
A ckn
ow led gem en ts
C L IN IC A L C O L LA B O R A T O R S
D r Se lw yn R ichard s, D o rset C FS Serv ice
D r Janice M a in, Im p erial C o llege L o nd o n
P ro fesso r T erry D aym o nd , Su nd erland
P ro fesso r A nd rew Sm ith, U niv ersity o f C ard iff
D r D av id H o neyb o u rne , B irm ingha m
D r A m o lak B ansal, St H elier H o sp ital, Su rrey
P ro fesso r Jo n A yres, A b erd een U niv ersity
P ro fesso r R o b ert P ev eler, U niv ersity o f So u tham p to n
P ro fesso r D av id N u tt, U niv ersity o f B risto l
D r Jo hn A xfo rd , St G eo rge’s U niv ersity of L o nd o n
D r R u ssell L a ne, C haring C ro ss H osp ital, L o nd o n
D r Jo hn K C hia, U C L A M ed ical C entre, C A , U SA
D r D erek E nla nd er, N Y , U SA
D r P au l L a ngfo rd , Im p erial C o llege L o n d o n
P ro fesso r M ike L ev in, Im p erial C o llege L o nd o n
FU N D IN G
C FS R esearch Fo u nd atio n, H ertfo rd shire, U K
ST U D Y D E SIG N & L A B O R A T O R Y W O R K
D eep ika D ev anu r, St G eo rge’s U niv ersity o f L o nd o n
R o b ert P etty, S t G eo rge’s U niv ersity o f Lo nd o n
B ev erley B u rke, St G eo rge’s U niv ersity of L o nd o n
N arend ra K au shik, Im p erial C o llege L o n d o n
R o b W ilk inso n, Im p eria l C o llege L o nd o n
C lare M cD erm o tt, D o rset C FS Serv ice
Jane M o ntgo m ery, D o rset C FS Serv ice
D av id Fear, K ings C o llege L o nd o n
T im H arriso n, U C L
P au l K ella m , U C L
D av id A J T yrrell, C FS R esearch Fo u nd atio n
Step he n T H o lgate, U n iv ersity o f So u tha m p to n
E m ile N u w aysir, N im b legen Inc, U SA .
D o n B ald w in, U niv ersity o f P ennsylv an ia, U SA
P eter R o gers, N B S
D ia na C arr, N B S
Ju lie W illiam s, N B S
Frank B o u lto n, N B S
A nd rew B ell, P o o le H o sp ital
CFS Gene microarray
M ic ro a rra y
kin d p e r m iss io n o f Jo n a th a n K e rr
Gene Microarray
M ic ro a rra y
CFS Associated genes
P ilo t
s tu d y
K e rr,
E n la n d e r
e t a l.
1 6 C F S -a sso c ia te d G e n e s
Im m u n e
IL -1 0 R A
C D 2BP2
IL -1 0 re c e p to r a lp h a
C D 2 a n tig e n b in d in g p ro te in 2
N e u ro lo g ic a l
PRKCL1
GA BA RA PL1
K H SR P
N TE
GSN
P ro te in k in a s e C -lik e 1
G A B A (A ) re c e p to r as so c ia te d p ro te in lik e -1
K H -ty p e s p lic in g re g u la to ry p ro te in
N e u ro p a th y ta rg e t e s te ra s e
G e ls o lin
M ito c h o n d rio n
M R PL23
E IF 2 B 4
E IF 4 G 1
M ito c h o n d ria l rib o so m a l p ro te in L 2 3
E u k . tra n s la tio n in itia tio n f a c to r 2 B , s u b u n it 4 δ , tv -1
E u k . T ra n s la tio n in itia tio n f a c to r 4 G , s u b u n it 1, tv -5
A p o p to sis / c e ll cy cle
PDCD2
A N A PC 11
BR M S1
P ro g ra m m e d c e ll d e a th 2 , tv -1
A n a p h as e p ro m o tin g co m p le x s u b u n it 1 1 h o m o lo g
B re a s t c a n c e r m e ta s ta s is s u p p re sso r 1
P e ro x iso m e
A BCD 4
PEX 16
A T P -b in d in g c a ss e tte s u bf a m ily D , m e m b e r 4
P e ro x iso m a l b io g e n es is f a c to r 1 6
T ra n s c rip tio n
PO LR 2G
R N A p o ly m e ra s e II (D N A -d ire c te d ) p o ly p e p tid e G
B io m ark ers
Diagnostic slide test
D iag n o stic test fo r C F S
**C o llab o ratio n w ith D ep t o f P aed iatrics, Im p erial C o lleg e L o nd o n
GcMaf
• GcMaf protein.. Gc Macrophage Activation
Factor original work Yamamoto
• Reduced by action of Nagalase
• Nagalase if increased GcMaf is decreased
• Research into ME/CFS serum nagalase levels
• Administration of GcMaf injection in
research protocol
• Cheney researches MAF 314 probiotic yogurt
• ME/CFS center researches MAF 878
probiotic
Ampligen
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Research treatment protocol
Thought to act on the immune system
5 centers chosen in US
California, New York, Utah, Carolina, Florida
Hemispherx part funding
Patient cost for 6 months $12,000
Not yet FDA approved
Retro Virus XMRV
• New retrovirus XMRV testing in Nevada…. Judy
Mikovits
• Exciting press releases Oct 2009
• Helps patients and doctors stress the physiological
aspect of CFS / ME
• Harvey Alter, NIH confirms MLV results 2010
• Small number of patients tested, not adequately replicated as yet
• Moderation in determining this as causative agent
• Researcher battle ensues
• Science requests withdrawal of original paper May 2011
•
WPI dismisses Dr Mikovits , sues her for stealing her own notebooks , jails her for 4 days
XMRV retro virus
• Whitmore Pederson
Institute, Reno, Nevada
• XMRV retro virus study
• Science journal publishes
article 8th Oct 2009
• Battle ensues by other
researchers some confirm,
other deny
• May 2011 Science asks Judy
Miklovits to withdraw
article
Dr Judy Mikovits
Proc. Natl. Acad. Sci. USA Vol. 88, pp. 2922-2926, April 1991
Medical Sciences
Retroviral sequences related to human T-lymphotropic virus
type II in patients with chronic fatigue immune dysfunction
syndrome (Epstein-Barr virus syndrome/infectious
mononucleosis/myalgic encephalomyelitis/polymerase chain
reaction/in situ hybridization)
ELAINE DEFREITAS*, BRENDAN HILLIARD, PAUL R. CHENEY, DAVID S.
BELLS, EDWARD KIGGUNDU, DIANE SANKEY, ZOFIA WROBLEWSKA, MARIA
PALLADINO, JOHN P. WOODWARD§, AND HILARY KOPROWSKI
The Wistar Institute, 3601 Spruce Street, Philadelphia, PA 19104 Contributed by
Hilary Koprowski, Nov13, 1990
ABSTRACT Chronic fatigue immune dysfunction syndrome (CFIDS)
is
a recently recognized illness characterized by debilitating fatigue as well as
immunological and neurological abnormalities [Straus, S. E. (1988) J. Inf. Dis.
157, 405412]. Once thought to be caused by Epstein-Barr virus, it is now
thought to have a different but unknown etiology. We evaluated 30 adult and
pediatric CFIDS patients from six eastern states for the presence of human Tlymphotropic virus (HTLV) types I and II by Western immunoblotting, polymerase
chain reaction,
Hepapressin complex treatment
Karnofsky & Fatigue scores
Cohort
population
Initiation
3 months
6 months
9 months
Control
Placebo
215
48 (2.4)
49 (2.6)
53 (2.4)
50 (2.3)
Kutapressin
/Hepapressin
alone
209
46 (2.6)
57 (2.4)
55 (1.8)
62 (1.5)
Kutapressin
/Hepapressin
complexed
210
47 (2.1)
47 (1.9)
64 (1.3)
74 (0.8)
Kutapressin
/Hepapressin
complexed
Immunoprop
Immunoplus
216
45 (2.5)
52 (1.7)
73 (0.9)
81 (0.5)
Ongoing research
 GcMaf / Nagalase…. Collaboration with Dr. Kenny deMeirleir
GcMaf
Study in treatment of CFIDS/ME patients
Ampligen treatment study
Part
Sponsored by Hemispherx Inc
B12 changes with BetaMax (sublingual methyl B12)
Average
increase 56% after avg. 3 months of use
Retrospective analysis of Carnitine in CFS
120
patients, randomly selected serum Carnitine Low
 Analysis of urinary H2S with Lead Arsenate
70
patients, randomly selected 35% positive Lead arsenate analysis
Proposed Research
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Retuximab
CMX 1000
Enbrel
Pre and post Exertional Malaise study
Retuximab Study
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Norwegian Study Oct 2011
ME/CFS Patients with lymphoma
ME/CFS seemed to improve after chemo
Initial study 5 patients
Followup with 15 patients 15 controls
Retuximab Study
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Patients have to be hospitalised overnight
Retuximab is a chemotherapeutic infusion
Administered monthly for 6 months
Not FDA / GMC approved
Past side effects including fatal outcome
Relapse 6 months after infusion completion
Reversed after second infusion
The UK and Ireland scene
• Problems in finding the diagnosis
• If diagnosis is made here or elsewhere problem in
finding suitable care and treatment
• Doctors are only given psychiatric methods of
treatment CBT & GET
• Research into physical aspect of ME/CFS is
neglected
• Disability is undercompensated
• National cost in GNP is estimated at 10,000
million pound annually
The UK and Ireland scene
• Provide research funds to physical diagnosis
and treatment
• Provide training to young doctors
• Provide information to old doctors
• Set up Central and regional ME/CFS centres to
diagnose and treat this physical disease
• Reverse old ideas of psychiatric treatment
Immediate Provisional solution
• Initiation and funding of two fellowships in the
diagnosis and treatment of ME/CFS by the
Government and/or Private sources
• We have set up the fellowship training for 12
months for two post Doc physicians
• The training will be provided at the ME/CFS
Centre in New York
• Dr Eric Schadt will supervise the research part of
the fellowship
• Dr Derek Enlander will supervise the clinical part
of the fellowship
ME/CFS Center
Mount Sinai Medical Center, New York
set up in Nov 2011 with a donation of one million dollars
by a patient of Dr Enlander
First ME/CFS centre in a major School of medicine
• Research in Genomics Eric Schadt
• Immunology Miriam Merad
• Virology Ila Singh
• Pulmonology Christian Becker
• Clinical diagnosis and treatment Derek Enlander
and David Bell