Research Advances in Chronic Fatigue Syndrome Nancy Klimas, MD University of Miami CFS and GWI Research Center Miami VA Medical Center

Definition - CFS >6 mo. debilitating fatigue, unexplained by preexisting illness or psychiatric co morbidity, and at least 4 of eight symptom criteria: post exertional relapse concentration and cognitive complaints myalgia arthralgia sore throat painful lymph nodes new headaches unrefreshing sleep

CFS/ME Clinical Case Definition 1. Substantial reduction in activity level due to new onset, persistent fatigue 2. Post exertional malaise 3. Sleep dysfunction 4. Pain – myalgia, headaches 5. Neurologic/Cognitive Manifestations 6. At least one symptom from 2 of the following: - Autonomic manifestations eg. OI, IBS - Neuroendocrine manifestations eg. temperature intolerance, weight change - Immune manifestations eg. tender lymph nodes, sore throat, flu-like symptoms Link to full report www.iacfs.net

CFS “Caseness” Subpopulations CFS Autonomic Immune HPA

CFS “Caseness” Subpopulations HPA Autonomic Immune

Other overlapping conditions Fibromyalgia Gulf War Illness (VA CSP 16 fold increased risk of CFS in Gulf War veterans) Eisen et al Ann Int Med 2005 7;142(11):881 Multiple Chemical Sensitivity

Epidemiology: DePaul University Latinos: 726 per 100,000 African Americans: 337 per 100,000 Caucasians: 224 per 100,000 Women: 522 per 100,000 Men: 291 per 100,000 CDC Wichita study: 85% undiagnosed, 50% reduction in household income – 9 billion/yr US loss productivity Jason et al Psychosom Med. 2000 Sep-Oct;62(5):655-63 Reeves et al Biomed Central 2005

Attitudes of Physicians Of 811 GP’s 44% did not feel confident making the diagnosis, 41% did not feel confident treating More likely to have confidence if they had a friend or family member with CFS, having more patients with CFS. Concludes that education emphasizing acceptance of CFS as a real entity results in improved confidence in treatment Bowen J et al Family Pract 2005 April 1

Model of CFS Pathogenesis Genetic Predisposition Triggering event / infection Mediators (Immune, endocrine, neuroendocrine, psychosocial) Health Outcome/Persistence

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)

Evidence for Triggering event/ infection - CFS 60 to 80% of CFS subjects date the onset of their illness to an acute viral-like illness (Komaroff, Buchwald) Less so in population based studies. (Reeves, Jason) Andrew Lloyd and colleagues in Australia performed a prospective study during and after acute EBV, Q fever or Ross River Virus -Anergy during acute infection predicted persistent CFS like symptoms Peter White described post EBV illness in a prospective trial

Model of CFS Pathogenesis Genetic Predisposition Triggering event / infection Mediators (Immune, endocrine, neuroendocrine, psychosocial) Health Outcome/Persistence

CRF CNS Symptoms Physical stress activates immune system and HPA axis 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-Pituitary-Adrenal 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

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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

Immunology What’s New? Exercise induced complement activation1 NK phenotypes predict risk 2 Lower mRNA and TGF-beta1 production 3 Increased neutrophil apoptosis 4 Autoantibodies - anti-microtubule-associated protein 2, sDNA5 CTL defect equals that of NK cells 1 Sorensen, Jones et al J Allergy Clin Immun 2003 112(2):397-403 2 Stewart et al Cytometry 2003 53(1)2633 3 Tomoda A et al Psychiatry Res 2005 134(1):101 4 Kennedy et al J Clin Parhol 2004 57(8) 891 5 Vernon and Reeves, J Autoimmune Dis 2005 25:2:5 6 Maher Fletcher and Klimas 2006 Jones group - allergy challenge did not predict relapse or cause complement activation, though exercise challenge did do so. C4a at 6hours post exercise challenge (nl’s also activate complement but return to nl levels within 3 hours) n=32, 29 controls Cdc GROUP CONFIRMED Jones findings during the exercise challenge gene expression study Stewart looked at cases and controls from cluster townships and noncluster townships, found few NK cells predicted cases in cluster towns, CD 8 cells were higher and NK cells lower in cases than controls, some regional differences relating to popuation density were seen (NYC looked different than rural controls)

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) Gow and colleagues made a similar claim in the early 90’s, then retracted. In this study none of the healthy controls were positive, 4 of 30 CFS/FM pts were positive and 3 of 15 with chronic inflammatory muscle disease, using PCR

HPA Axis dysregulation Demitrack low basal cortisols in CFS subjects, hypothalamic dysfunction- Dinan and colleagues - evidence of deficiency of hypothalamus, pituitary, and adrenal hypofunction. Small adrenal gland in depressed and non depressed CFS subjects, enlarged adrenal in depressed control group. Bennett et al studied 500 FM patients with basal IGF-I levels which were significantly lower than controls.

Endocrinology Reduced Cortisol output via several mechanisms A) heightened negative feedback B) heightened receptor function C) impaired ACTH and cortisol responses to challenge DHEA functional abnormality (early data) Abnormal seritonin function IL-6 increase associates with low cortisol CRH mediated Many confounding factors (deconditioning, sleep, comorbid depression, stress, medication) Cleare AJ Endocr Rev 2003 24(2):236-52 Papanicolau Neuroimmunomodulation 2004 11(2)65-74 Maes M Neuro Endocrinol Lett 2005 Oct 30;26(5) IL-6 is also secreted by adipose tissue, may relate to level of excess

Renin Aldosterone Axis High Prevalence of Renin-Aldosterone Axis Abnormalities in Patients with Chronic Fatigue Syndrome (CFS) 30 of the 33 patients had at least one value of supine or upright PRA or supine or upright serum AL outside of the 95% Tolerance Interval (TI) for normal volunteers 16 patients had low serum AL and low or normal PRA, consistent with Hyporeninemic Hypoaldosteronism (HH) The underlying defect may be autonomic nervous system dysfunction and/or a primary adrenal defect. Plasma Renin activity (PRA), serum Aldosterone levels (AL), Blood Pressure and pulse in the supine position for 10 minutes, and 30 minutes after standing were measured in 33 patients meeting the CDC-criteria for CFS as well as 12 healthy volunteers. Zuckerbraun, E, Kim, HS, Daigle, K, Lee, ML, Friedman, TC, Charles R. Drew University

Autonomic Dysfunction Neurally mediated hypotension (Rowe) Orthostatic hypotension (Streeten) Parasympathetic dysfunction(Sisto) Sympathetic over activation (Pagini, De Becker) Study in adolescents mirrored that of adults

sympathetic parasympathetic Balancing Act sympathetic parasympathetic

Autonomic Nervous System Haemodynamic Instability Score taken during tilt table testing predicts CFS with 90% sensitivity. 1 Heart Rate variability as a predictor of CFS 2 Gastric emptying delayed in 23/32 CFS subjects 3 1 Naschitz QJ Med 2003 96(133-142) 2 Yamamoto Exp Biol Med 2003 228(2):167-74 3 Burnet BMC Gastrenterol 2004 (1):32 40 CFS patients compare to 278 non CFS subjects witheither FM, syncope, anxiety, htn, familial mediterranean fever and 59 controls. 90% of CFS pts scored above the threshold, 21% of CF (non CFS) group, 18% of syncope group, 13% FM, 12% of healthy controls, 8% FMF, 3% HTN. His work predicts the usefulness of alpha 1 agonists in this conditin (eg midodrine) Yamamoto et al looked at 24 female CFS patients and 22 controls, found HRV ( a decrease in the aperoid fractal component of HVR) had a 90 sensitivity and 72% specificity for CFS dx. 3 – Johns Hopkins group – N=26 cfs 23 controls, failed to confirm speculations about decreased blood flow using this method. Methodologic issue – other studies supine have shown decreases in cerebral blood flow on demand (mental task) using SPECT scans

Autonomic Dysfunction Drops in BP followed by CFS relapse Exhaustive treadmill testing results in cognitive function decline (LaManca et al) Perfusion abnormalities of brain stem, cerebellum (Costa et al) Mid cerebral reduced perfusion (Schwartz et al)

Neuropeptides Seritonin and its precursers: abnormalities of CSF tryptophan levels Badawy et al J Psychopharm 2005 19(4):385 PET scan – 5HT1A receptor binding reduced in CFS, particularly in the hippocampus Cleare AJ et al Biol Psychiatry 2005 1;57(3):239-46 Reduction of seritonin transporters (5HTTs) most pronounced in the anterior cingulate by PET scan. Yamamoto S et al Neuroreport 2004 15(17):2571

Neuroimaging Reductions in global grey matter associated with reductions in physical activity (28 subjects, 28 matched controls). deLange et al Neuroimage 200526(3):777 Utilization of more extensive regions of the brain to process tasks using fMRI and mPASAT. Lange G et al Neuroimage 2005 26(2):513

Sleep Physiology Circadian Sleep - Wake neuroendocrine and immune functions in CFS (Modolfsky) altered diurnal patterns in cortisol, prolactin altered diurnal patterns of NK cell function alpha wave intrusion on sleep EEG , reduced stage III and IV Higher %REM (Twin study, 22 discordant twins)1 1 Watson et al Sleep 2003 26(3):32-8

Muscle Oxidative stress study, measuring protein carbonyls suggested higher levels of protein oxidation than controls 1 Exercise testing in 189 CFS subjects resulted in clinically significant subgroups 50% showing moderate to severe functional impairment. Unexpected blunted HR and BP responses noted. 2 Sarcoplasmic reticulum defect – conduction and calcium transport abnormalities3 1 Smirnova et al Mol Chem Biochem 2003 248(1-2):93-5 2 Vaness Med Sci Sports Exerc 2003 35(6):908-13 3 Fulle et al Neuromuscul Disord 2003 13(6):479-84 Peckerman study 38 CFS, 27 controls impedance cardiography – cardiac out put also correlated with cognitive symptom severity – suggests this is one subgroup of CFS blood volume increase could make this group theoretically worse. The exercise study noted gender differences – more women met mod to severe criteria, despite VO2 max levels that were close to predicted. 55% mod to sever, 35%% mild, 10% no impairment by exercise tolerance criteria. Fulle et al – suggest a membrane fluidity abnormality may be at fault for the observed findings

Muscle Cardiac muscle – cardiac output related to severity,and predicted exercise induced relapse1 Subset of CFS patients with IgM EBV or CMV Ab at risk for cardiac motility abnormalities and occassionally true cardiomyopathy 2 Raises the issue of incomplete viral replication, activating immune responses as suggested by Glaser et al 3 Lerner study incomplete viral particles in 49 CFS patients with abnormalities of igM, none of 170 controls of these 10 had abnormal cardiac wall motion at rest and 22 with exercise 1 Peckerman et al AJ Med Sci 2003 326(2)55 2 Lerner M et al In Vivo 2004(18) 4:417 3 Glaser R Brain Behavior Immun 2005 19(2):91

Exercise – new studies No association between pain related fear of movement and exercise capacity and disability Nijs J et al Phys Ther 2004 84(8):696 Exercise induced pain thresholds increase in controls and decrease in CFS subjects Whiteside A et al Pain 109(3):497 Clauw’s group Very small study 5 matched sets AMPLIGEN study 35 men 71 women no gender effect

Exercise – new studies A subset of fit healthy controls deprived of exercise develop symptoms similar to CFS/FM. The subset is predicted by baseline abnormalities of autonomic, immune and HPA axis abnormalities.1 Patients with Rnase L abnormalities have abnormal exercise physiology which is mediated in part by immune dysfunction 2 Response to exercise shows accentuated oxidative stress, and marked alterations of muscle membrane excitablility, sufficient to explain muscle pain and post exertional malaise. 3 Clauw’s group Very small study 5 matched sets AMPLIGEN study 35 men 71 women no gender effect 1Glass JM et al J Psychosom res 2004 57(4):391 2 Snell CR In Vivo 2005 19(2)387, Nijs J et al Med Sci Sports Exerc 2005 Oct 37(10):1647 3 Jammes Y et al J Intern Med 2005 257(3):229

Model of CFS Pathogenesis Genetic Predisposition Triggering event / infection Mediators (Immune, endocrine, neuroendocrine, psychosocial) Health Outcome/Persistence

Molecular Epidemiology Laboratory Strategy DNA Protein Abundance Protein Function mRNA Genomics Proteomics Activity-based Protein Profiling

Microarray Technology Robotic printing PCR amplification Purification DNA clones oligonucleotides Microarray Production . . . . . . . . . . . . . . . Total RNA Sample Preparation PBMCs Lymphoprep Erythrocytes + Granulocytes Plasma Blood Labelled cDNA Hybridization

23 women with CFS from Wichita Measure expression of 3,800 genes Sudden onset Gradual onset 23 women with CFS from Wichita Measure expression of 3,800 genes Question: Could gene expression profiles and differentially expressed genes distinguish subtypes of CFS? Of the 3,800 genes, 117 were significantly Different between gradual vs sudden onset

Differentially Expressed Genes in Numerous Pathways

Genetic studies Differential expression of 35 genes of 9522 tested. T Cell activation, neuronal and mitochondrial regulatory abnormalities Kaushik J Clin pathol 2005 58(8):826 Abnormalities of Immune response genes in post-infection fatigue suggest genetic variations in susceptibility to persistent fatigue. Helbig QJM 2005 98(8):565 Pre-post exercise challenge gene studies saw differences in genes that regulate ion transport, intracellular cell functions. Challenge studies such as these may be more useful than single cross sectional studies. Whistler et al BMC Physiol 2005 24;5(1):5

CFS is a Complex Illness Illness represents alterations in complex systems of homeostasis Not a result of a single mutation or single environmental factor Arise from a combined action of many genes, environmental factors and risk-conferring behavior

Treatment Pathogenesis based approaches

Pathogenesis Directed Interventions Immune - Ampligen, future immunomodulators HPA axis interventions - Growth hormone, cortisol NMH treatments (plasma expansion, sympathetic and parasympathetic stimulants/inhibitors); Sleep - pharmacologic and nonpharmacologic

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Immune modulatory approaches Ampligen, a immune modulator and antiviral (Phase 3 recently completed) Allergy immunotherapy to down regulate allergic drive Future immunomodulators (trials underway): Isoprinosine, thalidomide, anti-TNFa monoclonal Ab Proof of concept: Autologous lymphocyte study

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 9 of 12 responders in high titer EBV plus HHV6 selected cohort , (Jose Montoya of Stanford) Placebo control trials have not been completed

sympathetic parasympathetic Autonomic Dysfunction Neurally mediated hypotension (Rowe) Orthostatic hypotension (Streeten) Parasympathetic dysfunction (Sisto) Sympathetic over activation (Pagini, De Becker) Balancing Act sympathetic parasympathetic

Implications for treatment - NMH “Pipes and a pump”, wired by the autonomic nervous system Fill the space - fluid vs. cells compress the space - alpha 1 agonists (e.g. midodrine), anti-phlebitic stockings regulate the pump - beta blockers

HPA axis interventions - Growth hormone – phase 1 (Antwerp study) Cortisol – conflicting phase 2 study results (London, NIH) Restoration of sleep cycle (circadian rhythm)

Sleep Re-establish circadian rhythm Conditioned response to bed - avoid bed for resting, reading, use bed for sleeping. Establish “bedtime”. Avoid short acting hypnotics (alpha trappers) tricyclics, doxepan are longer acting, and don’t trap in alpha wave mirtazapine (Remeron), sodium oxybate or gamma hydroxybutyrate, (Xyrem) act as stage 4 inducers I. Jon Russell, associate professor of medicine at the University of Texas Health Science Center at San Antonio and the study’s lead researcher, along with his colleagues Drs. Robert M. Bennett in Portland and Joel E. Michalek in San Antonio, conducted a randomized, double-blind, placebo-controlled, multi-center clinical trial. The centers randomized 188 fibromyalgia syndrome patients to receive active treatment with one of two doses of sodium oxybate or with a placebo. One active treatment group took 4.5 grams of sodium oxybate per night, while a second group took 6 grams per night. The sodium oxybate was administered at night in two oral doses. The trial lasted eight weeks. Before they began to take the study medication, all of the study participants were withdrawn from other medications used to treat their fibromyalgia symptoms. Of the 147 patients who completed the trial, 51 took 4.5 grams per day, 44 took 6 grams per day and 52 took a placebo. Study Results “We saw significant clinical benefit with both doses of sodium oxybate compared with placebo,” Dr. Russell stated in the press release. “The patients’ self-reported pain and their perceptions of how well they slept improved among both dosage groups. The tenderness found during in-office examinations was significantly improved with the 6 gram dose.”

Pain and Sleep pregabulin (Lyrica) 529 subjects, placebo control trial in fibromyalgia Significant improvement in pain, sleep and fatigue (48% improved vs 27% placebo), 450 mg dose had greater reduction in pain scores. According to a study published in the April 2005 issue of Arthritis & Rheumatism, the medication Lyrica (generic name pregabalin): significantly reduced the pain of fibromyalgia syndrome improved sleep and fatigue improved other patient-reported conditions including bodily pain and vitality Fibromyalgia is characterized by widespread pain, fatigue, and sleep problems. Fibromyalgia is difficult to treat. The cause is unknown and there is no approved treatment which eliminates or controls the primary symptoms of fibromyalgia. In the study, which was an eight-week double-blind trial led by a University of Kentucky physician, 529 fibromyalgia patients were randomized to receive one of three daily doses of Lyrica (150, 300, or 450 mgs.) or placebo. The primary objective of the study was reduction in severity of pain. Statistics about the study participants reveal that, on average, patients were women in their late 40s who had long histories (average duration nine years) with fibromyalgia. The study participants had moderate to severe pain and diminished quality of life. Prior to the onset of the trial, study participants discontinued all medications for pain and sleep except acetaminophen, aspirin, or symptomatic migraine treatment. The benefit of Lyrica for fibromyalgia was demonstrated as early as the first week of treatment. A significantly greater proportion of patients receiving Lyrica versus placebo (48% vs. 27%) exeprienced a clinically meaningful reduction in pain. What defines a clinically meaningful reduction in pain? It is defined as a 30% or greater improvement in pain. Significantly more patients taking 450 mg per day Lyrica experienced a 50% or greater reduction in pain at the end of the study compared with placebo, (29% vs. 13%).Using daily sleep diaries and a sleep scale measurement, patients taking Lyrica reported significant improvement in sleep compared to those receiving placebo. Patients taking Lyrica also reported reduced fatigue on a scale of severity, distress, degree of interference in activities of daily living, and timing.

Nutritional interventions Oxidative stress studies suggest interventions such as glutathione, N-acytylcysteine, alpha lipoic acid, NADH Vitamin studies suggest B vitamins, Vitamin C, magnesium, sodium, zinc, l-tryptophan, L carnitine, co-Q10, and essential fatty acids highlighted interventions have phase 2 studies published

Nutritional interventions Dangers: Licorice root – potassium deficiencies “supplements” that are actually hormones “supplements” that have iffy contents – eg. St John’s wort, melatonin Products that make unsubstantiated claims Under and over hydration

Reconditioning Poor orthostatic resilience leads to substantial changes in usual reconditioning programs Limit upright head up time to 5 minutes alternating with 5 minutes flat, use flat or near flat aerobic conditions (swimming, recumbent bike) Concentrate on muscle bulking exercises, increasing metabolic ate (weight training, light weights) Flexibility , stretching and balance as core component.

Recent reports - interventions Brewers Yeast Extract - in a mouse model , using a chronic immune activation model, the BYE prep quieted the immune response and prevented further over activation in subsequent immune challenges. Activity level increased in the treated animals as compared to placebo Use of antibiotics for Coxiella burnetii infection(Q fever). TCN was given to 4 CFS patients and 58 ICFS PCR positive patients: all cleared the infection, CFS patients failed to improve, ICFS patients improved in performance and in temperature and headaches scores. Neurotropin - 6 mo treatment resolved all symptoms. Neurotropin is a immune modulator that is currently used in Japan to treat RSD and other painful conditions. Toda Hiroshima J Med Sci 2006 mar 55(1) 35-77. Takasha Evid based Compl Alt Med 2006 mar 3(1)109 Twakami et al Intern Med 2005 Dec 44(12):1258-63

Recent reports - interventions Melatonin 29 patients, 5mg open label study, 8 of 27 normalized fatigue scores. Measured patients dim light melatonin onset, patients whose result was later than 22 hours were more likely to respond to treatment. Methylphenidate (ritalin) in CFS 10 mg BID study in 60 patients, placebo control: 17% reported decreased fatigue, 22% improvement in concentration. ..further studies needed. Modafinil not helpful (N=14 cross over study) – mixed effect on cognitive testing, some dose effect. Van Heukelom et al Eur J neurol 2006 Jan 13(1):55-60 Blockman D et al Am J Med 2006 feb 119(2):167 Randall DC et al J Psychopharm 2005 nov 19(6): 647-60

Recent reports - interventions Walking program notes an initial ability to meet goals (4 to 10 days), then develop exercise intolerance and worsening symptomatology Patients report: of 155 patients taking everything under the sun, most helpful supplements coQ10 (69%) DHEA (65%), ginsing (56%) by self report. Vitamins, exercise, yoga, predicted improvement. Yoga seemed the most helpful. Black CD and McCully KK. Dyn Med 2005 Oct 28;3:10 Bentler SE J Clin Psychiatry 2005 may 66(5):625

University of Miami CFS Research and Clinical Center– Research Protocols SMART Energy Study (CBT) Erythropoetin (Procrit) phase 2 protocol Pathogenesis of NK cell defect in CFS Thalidomide Phase 1 protocol Isoprinosine Phase 2 protocol Natural history study Gene expression with exercise challenge in CFS and GWI

Conclusion There has been significant progress in our understanding of CFS . The neuroendocrine, immune, and central nervous system are linked, and can’t be considered separately. More effective therapies, based on this new understanding are available, with others under study.

All CFS patients can experience a better quality of life with compassionate care and a multidisciplinary approach.

Thank You! Professional links: AACFS on line: www.aacfs.org CDC on line: www.cdc.gov NIH on line: www.nih.gov Advocacy organizations: CFIDS Association of America On-line: www.cfids.org Information: info@cfids.org American Fibromyalgia Syndrome Assn. Online: www.afsafund.org National Gulf War Resource Center online: www.ngwrc.org New Zealand: Associated Myalgic Encephalopathy Society Inc www.anzmes.org.nz

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