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

2. 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

3. 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

4. CFS “Caseness”
Subpopulations
CFS
Autonomic
Immune
HPA

5. CFS “Caseness”
Subpopulations
HPA
Autonomic
Immune

6. 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 ;142(11):881
Multiple Chemical Sensitivity

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

8. 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

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

10. 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)

11. 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

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

13. 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

14. .

15. 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

16. 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 (2):
2 Stewart et al Cytometry (1)2633
3 Tomoda A et al Psychiatry Res (1):101
4 Kennedy et al J Clin Parhol (8) 891
5 Vernon and Reeves, J Autoimmune Dis :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)

17. 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 (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

18. 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.

19. 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 (2):236-52
Papanicolau Neuroimmunomodulation (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

20. 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

21. 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

22. sympathetic parasympathetic
Balancing Act
sympathetic parasympathetic

23. 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 ( )
2 Yamamoto Exp Biol Med (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

24. 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)

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

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

27. 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 (3):32-8

28. 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 (1-2):93-5
2 Vaness Med Sci Sports Exerc (6):908-13
3 Fulle et al Neuromuscul Disord (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

29. 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 (2)55
2 Lerner M et al In Vivo 2004(18) 4:417
3 Glaser R Brain Behavior Immun (2):91

30. Exercise – new studies
No association between pain related fear of movement and exercise capacity and disability Nijs J et al Phys Ther (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

31. 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 (4):391
2 Snell CR In Vivo (2)387, Nijs J et al Med Sci Sports Exerc 2005 Oct 37(10):1647
3 Jammes Y et al J Intern Med (3):229

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

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

34. 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

35. 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

36. Differentially Expressed Genes
in Numerous Pathways

37. Genetic studies
Differential expression of 35 genes of 9522 tested. T Cell activation, neuronal and mitochondrial regulatory abnormalities Kaushik J Clin pathol (8):826
Abnormalities of Immune response genes in post-infection fatigue suggest genetic variations in susceptibility to persistent fatigue. Helbig QJM (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 ;5(1):5

38. 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

39. Treatment
Pathogenesis based approaches

40. 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

41. .

42. 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

43. 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

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

45. 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

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

47. 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.”

48. 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.

49. 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

50. 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

51. 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.

52. 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)
Takasha Evid based Compl Alt Med 2006 mar 3(1)109
Twakami et al Intern Med 2005 Dec 44(12):

53. 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):

54. 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 may 66(5):625

55. 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

56. 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.

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

58. Thank You! Professional links: AACFS on line: www.aacfs.org
CDC on line:
NIH on line:
Advocacy organizations:
CFIDS Association of America
On-line: Information:
American Fibromyalgia Syndrome Assn.
Online:
National Gulf War Resource Center online:
New Zealand: Associated Myalgic Encephalopathy Society Inc

59. Photo by Leventhal, Karnovsky and Martz