Transcript Slide 1

Immunology and Infection
in Chronic Fatigue Syndrome
Nancy Klimas, MD
UNIVERSITY OF
Miami
SCHOOL OF MEDICINE
Model of CFS
Pathogenesis
Genetic Predisposition
Triggering event / infection
Mediators (Immune, endocrine, neuroendocrine,
psychosocial, viral reactivation or persistence)
CFS/ME
Genetic Predisposition - CFS



HLA DR haplotypes in 112 South Florida CFS
patients, compared to 5,000 regional and
national controls
4 to 6 fold increased relative risk for DR4, DR3
and DQ3. (Keller et al, 1992)
Seattle CFS Cooperative Research Center
Twin study - genetic predisposition,
hereditability estimate of 51% (2nd World
Conf); similar results in Sweden, Australian
studies
Evidence for Triggering event/
infection - CFS



60 to 80% of CFS subjects onset an acute virallike illness (Komaroff, Buchwald) Less so in
population based studies. (Reeves, Jason)
Andrew Lloyd and colleagues in Australia
performed a prospective study - anergy during
acute infection predicted persistent CFS like
symptoms
Severity of initial infection single best predictor
Model of CFS
Pathogenesis
Genetic Predisposition
Triggering event / infection
Mediators (Immune, endocrine, neuroendocrine,
psychosocial, viral reactivation or persistence)
CFS/ME
CRF
CNS Symptoms
• Altered perceptions
- fatigue
- pain
• Cognitive changes
- concentration
- memory
• Mood alterations
- depression
- anxiety
• Sleep disturbances
- unrefreshing sleep
- altered sleep-wake cycle
Physical stress activates
immune system and HPA
axis
Emotional stress activates
immune system and HPA
axis
Hypothalamic-PituitaryAdrenal Axis
• Relative Hypocortisolemia
Musculoskeletal System
• Myalgia & Arthralgia
Gastrointestinal Tract
• Altered bowel habits
• Abdominal pain
Heart and Blood Vessels
• Altered blood pressure
responses
• Dizziness
Immune System
• Lymph node tenderness
• Sore throat
• Enhanced Cytokines
Video link: The leukocyte

.
http://www.studiodaily.com/main/searchlist/6850.html
http://multimedia.mcb.harvard.edu/media.html
Immune cascade
Macrophage presents antigen
Natural Killer
Cells(Th1)
Helper CD4 cell
Th1 cytokines
IL-2, INF
activates CD8
.
Helper CD4 cell
Th2 cytokines
IL-6, IL-10
activates B cells
CD8 cells
kill virus
B cells
make antibody
prevent and help
clear infection
Immune abnormalities in CFS
Immune Activation



DR, CD26 expression
TH2 cytokine shift
Proinflammatory
cytokines expression
TNF-a, IL-1, IL6
Functional defects
NK Cell dysfunction
CD8 abnormalities
perforins, granzymes
Macrophage abnormalities
Antibody production
Photo by Leventhal, Karnovsky and Martz
NK Cytotoxicity: % K562 Cells Killed at Target to Effector Cell Ratio of 1:1
40
35
30
25
GWI
20
CFS
15
Controls
10
5
0
Subjects
Natural Killer Cell
Perforin is a molecule in cytotoxic
lymphocytes necessary for killing
of virus infected and tumor cells.
Cell Surface Antigen:
CD56
Intracellular
Cytolytic Granules:
* Perforin
* Granzyme A
* Granzyme B
Natural killer (NK) cell cytolytic capacity
was measured by quantitative flow
cytometry of intracellular content of
perforin, with data expressed as relative
number of molecules of perforin per CD3CD56+ lymphocyte (rMolPer/NK cell).
Intracellular Perforin
7000
6000
5000
4000
GWI
3000
CFS
Controls
2000
1000
0
Subjects
8000
Perforin
p = 0.01
rMolecules /
NK Cell
p = 0.05
6000
4000
2000
0
Lo NKCC
Hi NKCC
C FS
C ont rols
Subject Groups
Perforin
2000
p = 0.01
p = 0.01
rMolecules /
CD3+CD8+ Cell
1600
1200
800
400
0
Lo NK CC
Hi NK CC
C FS
C ont rols
Subject Groups
CD26 (dipeptidyl peptidase IV) is involved in
the activation of T cells, and is expressed on
antigen-reactive memory T cells.
As reported by the Miami CFS research group, the
percentage and number of CD26+ lymphocytes is
elevated in CFS.
Lymphocyte Activation in GWI and CFS:
Percent of CD2+CD26+ Lymphocytes
70
60
50
40
GWI
30
CFS
Controls
20
10
0
Subjects
Qualitative flow cytometry showed fewer
numbers of molecules of DPPIV/CD26 on T and
NK cells in CFS patients.
8000
6000
Molecules of CD26 on T Cells
p < 0.0002
4000
2000
0
Controls
CFS
Neuropeptide-Y (NPY) is peptide,which participates
in the regulation of a large number of physiological
and pathophysiological processes in the
cardiorespiratory system, immune system, nervous
system and endocrine system.
NPY is stored in sympathetic nerve terminals and is
released along with catecholamines during stressinduced activation. Only a few peptidases are capable
of cleaving NPY due to its unique 3-diminsional
structure. DPPIV/CD26 is one such peptidase.
In the GWI patients, we found a reduced
amount of NPY in plasma.
BIOMARKER
NPY (pmol/L)
GWI
37*
CFS
41
*Significantly different from HC (p<.05)
HC
52
LYMPHOCYTE PROLIFERATION IN RESPONSE TO PHA: MEAN (+/- S.D.) NET CPM
.
IN CFS PATIENTS ABOVE OR BELOW THE MEAN ON COGNITIVE DIFFICULTIES SCALE
.
..
210000
180000
150000
120000
P = .O3
90000
60000
30000
LOW CDS
HIGH CDS
Medical Outcom es S ur vey S hor t For m -36 ( S F-36)
Wom en with CFS
.
80
Group Means (+/- SD )
• .
• .
65
p = .003
50
35
20
5
LOW NKCC
N = 22
NORMAL NKCC
N = 19
SF-36 measures the impact of illness including limitations due to physical health,
pain, vitality, social functioning, emotional problems and general mental health.
Paced Auditory Serial Addition Task (PASAT)
Women with CFS
55
p = <.001
41
28
14
Group Means (+/- SD)
Low NKCC
n = 22
0
Normal NKCC
n = 19
The PASAT is an objective measure of:
rate of information processing, sustained attention and divided attention
Immune –Endocrine Link
IL-6 increase associates with low cortisol, CRH
mediated
Papanicolau Neuroimmunomodulation 2004 11(2)65-74
Maes M Neuro Endocrinol Lett 2005 Oct 30;26(5)
Viral Persistence/Reactivation
HHV6 virus is present in 22 to 54% of patients in cross
sectional studies (Ablashi, Krueger, Knox), HHV6
virus is present in 79% of CFS patients in
longitudinal studies (HHV6 PCR assay, Knox)
HHV6 virus is present in the spinal fluid of 28 of 120
CFS patients (Peterson), and 7 of 35 CFS samples
(Knox).
Enterovirus is present in 13% of CFS muscle samples
(Douche-Aourik, 2003);
EBV – dUTPase as a immune modulator, up regulating
inflammatory cytokines (Glaser, 2005)
(Glaser et al Brain Behavior and Immunity 2005 19(2):91-103)
Viral and Immune Interactions and
Health

J Chia showed GI biopsies with enterovirus
inclusions, found in patients with CFS and
abdominal complaints
Novel mechanisms of virus
mediated chronicity
Glaser et al found evidence of regulatory peptides
encoded by EBV expressed in CFS despite the
absence of replicative virus
 These peptides are known to modulate immune
function, inducing pro-inflammatory and Type 2
cytokines
 Lerner’s group found evidence of a subgroup of
CFS patients with incomplete viral expression and
cardiac motility abnormalities; subset of CFS with
2 Lerner
M etEBV
al In Vivo 2004(18) 4:417; (18)2:101
IgM

3 Glaser R Brain Behavior Immun 2005 19(2):91
Treating HHV6a?
Association vs. causation






Blood PCR HHV6 a did not predict HHV6 virus is present in
the spinal fluid
CSF did not predict blood
Of 120 CSF samples, 44 had abnormalities of protein, glucose
or cells. Of the 44 , 28 were positive for HHV6(26), EBV (1),
or CMV(1).
5 of 8 CSF PCR positive treated until CSF cleared returned to
full time employment (Peterson); in his experience TK
inhibitors did not clear CSF, patients required foscarnet or
cidofovir
Open label valgancyclovir 20 of 23 responders in high titer
EBV plus HHV6 selected cohort , (Jose Montoya)
Placebo control trials have not been completed
Clinical Trials

M Lerner reported a phase 1 trial of
valgangciclovir in CFS patients with
evidence of cardiac dysfunction. 37 patients
were treated in an open label study, with
improvement in all 37. He emphasized the
need to hydrate, monitor renal and liver
function.
Genomics, Proteomics, and Viral
Chips






IACFS Conf 2007 :
Inflammation pathways, IL-6, TNFa upregulated
in a subgroup, suggesting monoconal ab
blockers as a treatment (Kerr, Vernon, Olano)
CFS proteome (Baruniuk)
Serum analysis using infrared spectroscopy
(Sakudo, Watanabe, Ikuta, Kuratsune)
28 potential microbes under study (Kerr)
Reno research group using viral chip technology
in CFS and CFS associated malignancy
Conclusion



Immune dysfunction in CFS contributes to the
overall symptom complex, and contributes to
the persistence of the illness, both directly and
through interaction with neuropeptides and
hormones.
There is increasing evidence of viral reactivation
in at least a subset of the patient population.
Interventive trials are currently focused on
HHV6 virus.
This work is helping to identify subgroups of
CFS patients, identifying biomarkers, and
potential treatment options.
Thank You!
Immunology/Virology:
Drs. Mary Ann Fletcher, Kevin Maher, Roberto Patarca
Autonomic:
Dr. Barry Hurwitz
Health Assessment:
Drs. Michael Antoni, Mary Catherine Segota, Jackie Junco
Professional links:
IACFS/ME on line: www.iacfs.net
CDC on line: www.cdc.gov
NIH on line: www.nih.gov
Photo by Leventhal, Karnovsky and Martz