Chronic Fatigue Syndrome / Myalgic Encephalomyelitis (CFS/ME): pathogenesis, diagnostic biomarkers & clinical trials Dr Jonathan R Kerr MD, PhD, FRCPath Sir Joseph Hotung Senior Lecturer in Inflammation St George’s University of London

Chronic Fatigue Syndrome (CFS)

Epidemiology

Prevalence of 0.5% More common in females (6:1) Sudden onset Preceding virus infection (‘flu-like illness, outbreaks, specific viruses) Exposure to toxins, chemicals, pesticides, vaccination Pre-existing emotional stress

Chronic Fatigue Syndrome (CFS)

Studies of Pathogenesis

Immune system Infection Nervous system Endocrine system Cardiovascular system Psychological function Genetic predisposition  IC’s,  IgG,  B cells,  NK Th2 phenotype cytokine dysregulation / chronic immune activation virus, bacterium paresis, visual loss, ataxia, confusion abnormal metabolism of 5-HIAA, A-V, 5-HT, PRL brain scan abnormalities slight  HPA axis vasodilatation depression & anxiety deduced from twin studies

Active infections / insults in 200 CFS patients

Enterovirus

Chlamydia pneumoniae

Epstein-Barr virus Recurrent VZV infection Parvovirus B19 infection Hepatitis C virus Cytomegalovirus Postvaccination (pn, MMR or flu) Toxic mould exposure Recurrent HHV-6 infection Unknown 3 2 1 3 3 3 109 18 6 6 44 Chia et al. Clin Infect Dis 2003;36:671-2.

Chronic Fatigue Syndrome (CFS)

Treatment

Graded exercise therapy (GET) Cognitive behavioural therapy (CBT) Immunological – IVIG, interferon, terfenadine, Pharmacological – hydrocortisone, NADH, DA agonist, MAOI, Vit B analog, galanthamine, fludrocortisone, antidep, SSRI, acyclovir, IFN inducer Supplements – magnesium Complementary / alternative – massage, osteopathy Other – buddy/mentor program specific treatment of virus infection

Hypothesis for prolonged fatigue / CFS

Insults I J K A B C D E F G H Initial processes Final common pathway(s) CFS

Overview of basic cell processes

Microarray

Microarray

GENES

Taqman real-time PCR Test gene Control gene

Pilot study Study of Gene Expression in Chronic fatigue syndrome Pilot study - 2005 Hypothesis: that abnormalities of gene regulation occur in CFS 25 CFS patients & 25 normal controls Gene levels determined by Microarray analysis (9,522 genes) & real-time PCR

Pilot study

16

CFS-associated Genes Immune Neurological Mitochondrion IL-10RA CD2BP2 PRKCL1 GABARAPL1 KHSRP NTE GSN MRPL23 EIF2B4 EIF4G1 IL-10 receptor alpha CD2 antigen binding protein 2 Protein kinase C-like 1 GABA(A) receptor associated protein like-1 KH-type splicing regulatory protein Neuropathy target esterase Gelsolin Mitochondrial ribosomal protein L23 Euk. translation initiation factor 2B, subunit 4δ, tv-1 Euk. Translation initiation factor 4G, subunit 1, tv-5 Apoptosis / cell cycle PDCD2 ANAPC11 BRMS1 PeroxisomeABCD4 Transcription PEX16 POLR2G Programmed cell death 2, tv-1 Anaphase promoting complex subunit 11 homolog Breast cancer metastasis suppressor 1 ATP-binding cassette subfamily D, member 4 Peroxisomal biogenesis factor 16 RNA polymerase II (DNA-directed) polypeptide G

GENES

Pilot study

Conclusion

A complex pathogenesis Support for a biological process in CFS

Hypothesis

Macrophage A working model of CFS T lymphocyte

Hypothesis

Macrophage A working model of CFS T lymphocyte cytokines, etc

GENES

What are the human and virus gene signatures of CFS?

Phase 1-continued Repeat microarray study CFS patients and normal controls Determine levels of ALL human and virus genes

Phase-1 cont.

Phase-1 continued Study

Clinical aspects 1. Diagnosis according to CDC criteria (Fukuda et al, 1994) 2. Assessment of health & associated symptoms: CIDI Cantab McGill Chalder MOS-SF36 SPHERE Pittsburgh

GENES

Virus & Human genes in CFS

Microarray study MPSS Study Microarray 47,000 human genes 27 CFS pts / 54 normals

East Dorset CFS Service

MPSS ALL genes sequenced 20 CFS pts / 20 normals

University of Cardiff

GENES

Microarray

MPSS

182 15 52 Immune Response Neurological genes Mitochondrial genes Selective Regulation

Phase-1 cont.

GENES

GENES

GENES

Human microRNAs in CFS

GENES

Confirmation of specificity of CFS gene signature Phase 2 Idiopathic CFS (n=500) Infection-associated CFS (n=50) Prolonged fatigue (n=50) Normal fatigue (n=25) Normals (n=100) Rheumatoid arthritis (n=50) Osteoarthritis (n=50) Endogenous depression (n=50)

GENES

Associations of CFS-associated genes with symptoms Phase 3 CFS-associated symptoms CFS-associated genes Time (12 months)

GENES

Virus genes in CFS

MPSS Study Known virus triggers

28 microbes

Herpesviruses Enteroviruses Parvoviruses Coxiella burnetii Mycoplasma pneumoniae Chlamydia pneumoniae etc.

etc.

28 microbes

TREATMENT DEVELOPMENT

Clinical trials of treatment candidates

Phase 4 Human NFKB IL-6 Interferon-b HIF1a T cell activation Acyclovir Pleconoril Clarithromycin Interferon-b Virus

TREATMENT DEVELOPMENT

Clinical trials of treatment candidates

Phase 4 Human NFKB IL-6 HIF1a T cell activation Interferon-b Virus Acyclovir Pleconoril Clarithromycin

Biomarkers

Development of a diagnostic test for CFS SELDI-PC

Biomarkers

SELDI-PC

Biomarkers

Diagnostic test for CFS

**Collaboration with Dept of Paediatrics, Imperial College London

Clinical Centres

Acknowledgements

CLINICAL COLLABORATORS Dr Selwyn Richards, Dorset CFS Service Dr Janice Main, Imperial College London Professor Terry Daymond, Sunderland Professor Andrew Smith, University of Cardiff Dr David Honeybourne, Birmingham Dr Amolak Bansal, St Helier Hospital, Surrey Professor Jon Ayres, Aberdeen University Professor Robert Peveler, University of Southampton Professor David Nutt, University of Bristol Dr John Axford, St George’s University of London Dr Russell Lane, Charing Cross Hospital, London Dr John K Chia, UCLA Medical Centre, CA, USA Dr Derek Enlander, NY, USA Dr Paul Langford, Imperial College London Professor Mike Levin, Imperial College London FUNDING CFS Research Foundation, Hertfordshire, UK STUDY DESIGN & LABORATORY WORK Deepika Devanur, St George’s University of London Robert Petty, St George’s University of London Beverley Burke, St George’s University of London Narendra Kaushik, Imperial College London Rob Wilkinson, Imperial College London Clare McDermott, Dorset CFS Service Jane Montgomery, Dorset CFS Service David Fear, Kings College London Tim Harrison, UCL Paul Kellam, UCL David AJ Tyrrell, CFS Research Foundation Stephen T Holgate, University of Southampton Emile Nuwaysir, Nimblegen Inc, USA.

Don Baldwin, University of Pennsylvania, USA Peter Rogers, NBS Diana Carr, NBS Julie Williams, NBS Frank Boulton, NBS Andrew Bell, Poole Hospital