Faecal Microbiome Transplantation (FMT) a promising treatment for CFS with IBS

A retrospective outcome study of 42 patients with Chronic Fatigue Syndrome, 30 of whom had Irritable Bowel Syndrome. Half were treated with oral approaches, and half were treated with faecal microbiome transplantation, by JN Kenyon, Shelly Coe, Hooshang Izadi in Human Microbiome Journal vol 13 August 2019 [https://doi.org/10.1016/j.humic.2019.100061]

 

Research abstract:

The gut microbiome comprises the community of microorganisms in the intestinal tract. Research suggests that an altered microbiome may play a role in a wide range of disorders including myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS).

Methods:
42 participants with ME/ CFS with Irritable Bowel Syndrome (IBS) were allocated into one of two groups, 21 were treated with standard oral approaches, which centred around various nutritional remedies, probiotics, prebiotics, dietary advice and lifestyle advice. The second group who had mostly failed using oral approaches, were treated with Faecal Microbiome Transplantation (FMT). Each patient received 10 Implants, each from a different screened donor, and the Implants were processed under anaerobic conditions. The transplant is delivered via a paediatric rectal catheter, which is inserted through the anus to reach the lower part of the sigmoid colon.

The results were assessed on a percentage basis before and after treatment, 0% being no improvement, 100% being maximum improvement. An exact non-parametric Mann-Whitney (one-tailed) test was used to compare medians from those on FMT compared with those receiving oral approaches only. On clinical experience over many years, the only way to judge improvement in Chronic Fatigue Syndrome as there is no test for Chronic Fatigue Syndrome, is my clinical assessment.

Results:
The median for the FMT group was found to be significantly higher compared to the oral treatment group (Mann-Whitney U=111.5, p=.003). Therefore, the FMT group improved to a greater extent (z=-2.761).

Conclusion:
This study shows that FMT is a safe and a promising treatment for CFS associated with IBS. Adequately powered randomised controlled trials should be carried out to assess the effectiveness of FMT in patients with CFS and IBS.

The First ME/CFS Fecal Transplant Study Suggests the Treatment Holds Promise

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Inflammatory proteins are altered in CFS

Inflammatory proteins are altered in chronic fatigue syndrome – a systematic review and meta-analysis, by Rebecca Strawbridge, Maria-Laura Sartor, Fraser Scott, Anthony J Cleare in Neuroscience & Biobehavioral Reviews, August 26, 2019 [https://doi.org/10.1016/j.neubiorev.2019.08.011]

 

Highlights:

  • 42 studies meta-analysed, testing 20 proteins between patients with CFS and controls
  • Patients had higher levels of 5 cytokines than controls (TNF, IL-2, IL-4, TGFb, CRP)
  • Group differences were not significant for 12 proteins
  • Results are heterogeneous but provide some support for an inflammatory role in CFS

Review abstract:

Immune dysfunction has been posited as a key element in the aetiology of chronic fatigue syndrome (CFS) since the illness was first conceived.  However, systematic reviews have yet to quantitatively synthesise inflammatory biomarkers across the literature.

We undertook a systematic review and meta-analysis to quantify available data on circulating inflammatory proteins, examining studies recruiting patients with a CFS diagnosis and a non-affected control group.

Results were meta-analysed from 42 studies. Patients with CFS had significantly elevated tumour necrosis factor (ES = 0.274, p < 0.001), interleukin-2 (ES = 0.203, p = 0.006), interleukin-4 (ES = 0.373, p = 0.004), transforming growth factor-β (ES = 0.967, p < 0.001) and c-reactive protein (ES = 0.622, p = 0.019). 12 proteins did not differ between groups.

These data provide some support for an inflammatory component in CFS, although inconsistency of results indicates that inflammation is unlikely to be a primary feature in all those suffering from this disorder. It is hoped that further work will elucidate whether there are subgroups of patients with clinically-relevant inflammatory dysfunction, and whether inflammatory cytokines may provide a prognostic biomarker or moderate treatment effects.

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Management of chronic fatigue syndrome/myalgic encephalomyelitis in a pediatric population: A scoping review

Management of chronic fatigue syndrome/myalgic encephalomyelitis in a pediatric population: a scoping review, by Sarah S Collard, Jane Murphy in Journal of Child Health Care, 4 Aug 2019 [https://doi.org/10.1177/1367493519864747]

Review abstract:

Chronic fatigue syndrome (CFS)/myalgic encephalomyelitis (ME) negatively impacts the quality of life for children with the condition. Although up to 2% of children have CFS/ME, the bulk of research investigates adults with CFS/ME. Using the PRISMA extension for a scoping review and the work of Arksey and O’Malley (2005), a scoping review was conducted of all relevant peer-reviewed research investigating nutrition, exercise, and psychosocial factors within a pediatric population diagnosed with CFS/ME.

Key themes found were nutrition and dietary components, exercise therapy, psychosocial factors, and multifaceted treatment. Nutrition was explored on its own as a tool to decrease symptoms; however, there were very few studies found to examine nutritional deficiency or treatment with those under the age of 18.

Graded exercise and resistance training improved fatigue severity and symptoms of depression in adolescents with CFS/ME. Research exploring psychosocial factors of CFS/ME presented attributes that could lead to being diagnosed as well as barriers to treatment. The multifaceted treatment undertaken typically consists of graded activities/exercise, cognitive behavioral therapy, nutritional advice, and family sessions. This has shown to increase school attendance and decrease the severity of the fatigue for adolescents.

Minimal literature exploring CFS/ME within a prepubescent population presents the need for further research.

 

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Brain responses in CFS & TMD to autonomic challenges

Brain responses in CFS and TMD to autonomic challenges: an exploratory fMRI study, by QC Vuong, JR Allison, A Finkelmeyer, J Newton, J Durham in JDR Clinical & Translational Research, August 28, 2019

 

Research abstract:

Introduction:
Dysfunction of the autonomic nervous system (ANS) is seen in chronic fatigue syndrome (CFS) and temporomandibular disorders (TMDs). Both conditions have poorly understood pathophysiology. Several brain structures that play a role in pain and fatigue, such as the insular cortex and basal ganglia, are also implicated in autonomic function.

Objectives:
ANS dysfunction may point to common neurophysiologic mechanisms underlying the predominant symptoms for CFS and TMD. No studies to date have investigated the combination of both conditions. Thus, our aim was to test whether patients with CFS with or without TMD show differences in brain responses to autonomic challenges.

Methods:
In this exploratory functional imaging study, patients with CFS who screened positive for TMD (n = 26), patients who screened negative for TMD (n = 16), and age-matched control participants (n = 10) performed the Valsalva maneuver while in a 3-T magnetic resonance imaging scanner. This maneuver is known to activate the ANS.

Results:
For all 3 groups, whole-brain F test showed increased brain activation during the maneuver in the superior and inferior frontal gyri, the left and right putamen and thalamus, and the insular cortex. Furthermore, group contrasts with small-volume correction showed that patients with CFS who screened positive for TMD showed greater activity in the left insular cortex as compared with patients who screened negative and in the left caudate nucleus as compared with controls.

Conclusion:
Our results suggest that increased activity in the cortical and subcortical regions observed during autonomic challenges may be modulated by fatigue and pain. ANS dysfunction may be a contributing factor to these findings, and further work is required to tease apart the complex relationship among CFS, TMD, and autonomic functions.

Knowledge Transfer Statement:
Brain activity related to activation of the autonomic nervous system in patients with chronic fatigue syndrome who screened positive for painful temporomandibular disorder was greater than in patients who screened negative; activity was seen in brain regions associated with autonomic functions and pain. These findings suggest that autonomic dysfunction may play a role in the pathophysiology of both conditions, explain some of the apparent comorbidity between them, and offer avenues to help with treatment.

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A systematic review of cytokines in CFS/ME/SEID

A systematic review of cytokines in chronic fatigue syndrome /myalgic encephalomyelitis/ systemic exertion intolerance disease (CFS/ME/SEID) by Matthew Corbitt, Natalie Eaton-Fitch, Donald Staines, Hélène Cabanas & Sonya Marshall-Gradisnik in BMC Neurology volume 19, Article number: 207 (2019) [Published: 24 August 2019]

 

Research abstract:

Background: Cytokines in Chronic Fatigue Syndrome/Myalgic Encephalomyelitis/ Systemic Exertion Intolerance Disease (CFS/ME/SEID) patients compared with healthy controls have been extensively studied. However, the evidence regarding whether a baseline difference between CFS/ME/SEID patients and the normal population remains unclear.

The aim of this study was to conduct a systematic review of the literature regarding cytokines in CFS/ME/SEID and whether there is a significant difference in cytokine levels between this patient group and the normal population.

Methods: Pubmed, Scopus, Medline (EBSCOHost), and EMBASE databases were searched to source relevant studies for CFS/ME/SEID. The review included any studies examining cytokines in CFS/ME/SEID patients compared with healthy controls. Results of the literature search were summarised according to aspects of their study design and outcome measures, namely, cytokines. Quality assessment was also completed to summarise the level of evidence available.

Results: A total of 16,702 publications were returned using our search terms. After screening of papers according to our inclusion and exclusion criteria, 15 studies were included in the review. All the included studies were observational case control studies. Ten of the studies identified measured serum cytokines in CFS/ME/SEID patients, and four measured cytokines in other physiological fluids of CFS/ME/SEID patients. The overall quality assessment revealed most papers included in this systematic review to be consistent.

Conclusions: Despite the availability of moderate quality studies, the findings of this review are inconclusive as to whether cytokines play any definitive role in CFS/ME/SEID, and consequently, they would not serve as reliable biomarkers. Therefore, in light of these results, it is recommended that further efforts toward a diagnostic test and treatment for CFS/ME/SEID continue to be developed in a range of research fields.

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Dr Nina Muirhead – video Q&A

Interviews with Dr Nina Muirhead

ME Suppport in Glamorgan (MESIG) has posted videos with Dr Nina Muirhead, who is a  dermatologist and person with ME.

Video 1: She answers the following questions:

  • What are your experiences as a ME sufferer?
  • How did you get diagnosed with ME?
  • How does ME affect your life?
  • How does ME affect the relationship to your children?

Video 2:

  • What is your perception of ME as a doctor?
  • What is the current biomedical research on ME?

Video 3:

  • What is your perception on educating doctors about ME?
  • What is the importance of local charities?
  • How has ME affected your working life?

Video 4:

  • What is your advice for other sufferers?
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Predictors of new onsets of IBS, CFS & FM: the lifelines study

Predictors of new onsets of Irritable Bowel Syndrome, Chronic Fatigue Syndrome and Fibromyalgia: The Lifelines study, by Rei Monden, Judith G Rosmalen, Klaas Wardenaar,  Francis Creed, Manuscript Number: THELANCET-D-19-04796 (July 26, 2019). at SSRN:

 

Research abstract:

Background:

It is unclear whether the functional somatic syndromes share a common etiology or have distinct syndrome-specific mechanisms. This prospective population-based study assessed whether the same variables predict new onsets of self-reported Irritablebowel syndrome (IBS), Chronic Fatigue Syndrome (CFS) and Fibromyalgia (FM).

Methods:

The study included adults participating in the Dutch Lifelines population-based study who reported the presence/absence of IBS, CFS or FM at baseline and follow-up (N=152,180). They were screened at baseline for physical and psychological disorders, ociodemographic, psycho-social and behavioral variables. At follow-up (mean 2.4 years) we identified new onsets of each syndrome by self-report. We performed separate analyses for the three syndromes, including only those participants who, at baseline, were free of the relevant syndrome or its key symptom. LASSO logistic regressions were applied to identify which of the 102 baseline variables predicted new onsets of each syndrome.

Findings:

The numbers of new onsets were 1,595 (1.2%), 296 (0.2%) and 692 (0.5%) for IBS, CFS, and FM respectively. LASSO logistic regression selected 26, 7 and 19 predictors for IBS, CFS and FM respectively. Four predictors were shared by all three syndromes: somatic symptoms, disturbed sleep, recent chronic illness and negative health perception. Female sex, allergies, gastrointestinal disorders, high BMI and low alcohol consumption predicted both IBS and FM; recent stress predicted both IBS and CFS but 28 predictors were specific to a single syndrome. CFS was more distinct from IBS and FM, which predicted each other.

Interpretation:

Syndrome-specific predictors were more common than shared ones. Such specific predictors might form a better starting point to unravel the heterogeneous etiologies of these syndromes than the current approach based on symptom patterns. The close relationship between IBS and FM is striking and the shared role of allergies, gastrointestinal and other medical disorders and medications needs further investigation.

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Antibodies to Human Herpesviruses in ME/CFS patients

Antibodies to Human Herpesviruses in Myalgic Encephalomyelitis/Chronic Fatigue Syndrome patients, by Jonas Blomberg, Muhammad Rizwan, Agnes Böhlin-Wiener, Amal Elfaitouri, Per Julin, Olof Zachrisson, Anders Rosén and Carl-Gerhard Gottfries in Front. Immunol., 14 August 2019, [https://doi.org/10.3389/fimmu.2019.01946]

 

Research abstract:

Myalgic encephalomyelitis, also referred to as chronic fatigue syndrome (ME/CFS) is a debilitating disease characterized by myalgia and a sometimes severe limitation of physical activity and cognition. It is exacerbated by physical and mental activity. Its cause is unknown, but frequently starts with an infection.

The eliciting infection (commonly infectious mononucleosis or an upper respiratory infection) can be more or less well diagnosed. Among the human herpesviruses (HHV-1-8), HHV-4 (Epstein-Barr virus; EBV), HHV-6 (including HHV-6A and HHV-6B), and HHV-7, have been implicated in the pathogenesis of ME/CFS.

It was therefore logical to search for serological evidence of past herpesvirus infection/ reactivation in several cohorts of ME/CFS patients (all diagnosed using the Canada criteria). Control samples were from Swedish blood donors. We used whole purified virus, recombinant proteins, and synthetic peptides as antigens in a suspension multiplex immunoassay (SMIA) for immunoglobulin G (IgG).

The study on herpesviral peptides based on antigenicity with human sera yielded novel epitope information. Overall, IgG anti-herpes-viral reactivities of ME/CFS patients and controls did not show significant differences. However, the high precision and internally controlled format allowed us to observe minor relative differences between antibody reactivities of some herpesviral antigens in ME/CFS versus controls.

ME/CFS samples reacted somewhat differently from controls with whole virus HHV-1 antigens and recombinant EBV EBNA6 and EA antigens. We conclude that ME/CFS samples had similar levels of IgG reactivity as blood donor samples with HHV-1-7 antigens. The subtle serological differences should not be over-interpreted, but they may indicate that the immune system of some ME/CFS patients interact with the ubiquitous herpesviruses in a way different from that of healthy controls.

 

Commentary  by Maria Eugenia Ariza

Introduction:

Studies to ascertain a possible relationship between herpesviruses and myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) have relied heavily on classical approaches, specifically, serological examination for antibodies against virus proteins, primarily structural, and/or increases in viral load (1–21).

These data have been conflicting due in part to several features: the heterogeneity of the disease, high prevalence of the herpesviruses in the population since they can establish lifelong infections, and differences between laboratories. Two additional problems lead to conflicting data in serological studies: which viral antigens are to be used for detection, and what is the possible relationship, if any, of these viral antigens to ME/CFS?

These are important questions that must be addressed for any data to provide meaningful insight into the possible contribution of a virus to the pathophysiology of ME/CFS. Although the experimental techniques used in Blomberg’s serological study were appropriate, the selection of specific herpesviruses and viral antigens studied gives a limited view of the humoral response in ME/CFS.

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HERV-K & HERV-W transcriptional activity in ME/CFS

HERV-K and HERV-W transcriptional activity in Myalgic Encephalomyelitis/Chronic Fatigue Syndrome, by Lucas S Rodrigues, Luiz H da Silva Nali, Cibele O D Leal, Ester C Sabino, Eliana M Lacerda, Caroline C Kingdon, Luis Nacul, Camila M Romano in BioRxiv, July 5 2019 [doi: https://doi.org/10.1101/693465]

 

Research abstract: 

Chronic Fatigue Syndrome/Myalgic Encephalomyelitis (CFS/ME) is an incapacitating chronic disease that dramatically compromise the life quality. The CFS/ME pathogenesis is multifactorial, and it is believed that immunological, metabolic and environmental factors play a role.

It is well documented an increased activity of Human endogenous retroviruses (HERVs) from different families in autoimmune and neurological diseases, making these elements good candidates for biomarkers or even triggers for such diseases. Here the expression of Endogenous retroviruses K and W (HERV-K and HERV-W) was determined in blood from moderately and severely affected ME/CFS patients.

HERV-K was overexpressed only in moderately affected individuals and HERV-W showed no difference. This is the first report about HERV-K differential expression in moderate ME/CFS.

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ME/CFS: a comprehensive review

Myalgic Encephalomyelitis/Chronic Fatigue Syndrome: a comprehensive review, by
Mateo Cortes Rivera, Claudio Mastronardi, Claudia T Silva-Aldana, Mauricio Arcos-Burgos and Brett A Lidbury in Diagnostics 2019, 9(3), 91; 7 August 2019[https://doi.org/10.3390/diagnostics9030091]

Review abstract:

Myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) is a debilitating chronic disease of unknown aetiology that is recognized by the World Health Organization (WHO) and the United States Center for Disease Control and Prevention (US CDC) as a disorder of the brain. The disease predominantly affects adults, with a peak age of onset of between 20 and 45 years with a female to male ratio of 3:1.

Although the clinical features of the disease have been well established within diagnostic criteria, the diagnosis of ME/CFS is still of exclusion, meaning that other medical conditions must be ruled out. The pathophysiological mechanisms are unclear but the neuro-immuno-endocrinological pattern of CFS patients gleaned from various studies indicates that these three pillars may be the key point to understand the complexity of the disease.

At the moment, there are no specific pharmacological therapies to treat the disease, but several studies’ aims and therapeutic approaches have been described in order to benefit patients’ prognosis, symptomatology relief, and the recovery of pre-existing function. This review presents a pathophysiological approach to understanding the essential concepts of ME/CFS, with an emphasis on the population, clinical, and genetic concepts associated with ME/CFS.

Excerpt from the Discussion:

The first clinicians to describe the syndrome, as reviewed earlier, immediately associated the disease with an ongoing infection. Nowadays, with a significant core of research, it is known that the disease has its pathophysiological sustenance in “three pillars” that continuously interact with each other: the immune system, the nervous system, and the neuroendocrine network. Table 1 offers a brief summary of the main features of the tissues involved in the “three pillars” hypothesis.

As can be seen in Table 3, current therapeutic strategies target several elements of the proposed neuro-immunoendocrine network, which also supports the “three pillars” hypothesis that we are discussing in this review. The immune system is involved in modulating neural plasticity, learning, and memory, although the precise link between these two seemingly distinct systems was, until recently, unclear [54]. The connection may be explained by the coevolution of the nervous and immune systems, as the two systems share mechanisms of stimulation, cell communication and signaling, gene regulation, and supracellular organization. The immune system supports the central nervous system (CNS) and aids functional recovery by facilitating the renewal, migration and cell lineage specification of neural progenitor cells [221].

The immune system is involved in the stress response, since stress activates the immune system, leading to peripheral inflammation that may ultimately contribute to the onset of a part of the symptomatology of the disease [222]. Indeed, stress has been shown to be an essential predisposing factor in the development of several neurodegenerative and psychiatric disorders [223]. The hypothalamic–pituitary–adrenal (HPA) axis and the systemic sympatho-adrenomedullary (SAM) system are essential modulators of stress response systems [224]. The HPA axis is an endocrine pathway that regulates standard stress response and merges with the immune system to maintain homeostasis [138,139].

Therefore, stress stimulates the release of glucocorticoids, particularly cortisol, which is able to cross the BBB and alter the transcription of proteins in the brain [225]. Glucocorticoids bind to the glucocorticoid receptor (GR), resulting in disassociation from the heat-shock protein, and promoting a structural change of the receptor that enables the glucocorticoid-GR complex to enter the nucleus. The glucocorticoid-GR complex binds to the glucocorticoid response element on the DNA, resulting in the activation of transcription of immune-mediator genes, among others [223,226]. Therefore, stress hormones, such as cortisol, have the ability to regulate the immune system.

However, HPA is not the only neuroendocrinological network that can interact with the immune system. The SAM is also activated by stress, leading to the release of catecholamines (e.g., epinephrine and norepinephrine) in the adrenal medulla in response to stress [134,227]. Catecholamines have been found to regulate the synthesis of immune system mediators through β-adrenergic receptor stimulation [226], suggesting an alternative pathway that links the neuroendocrine and immunological systems.
ME/CFS patients show heightened negative feedback inhibition of the HPA axis, which is associated with hypocortisolism and heightened GR sensitivity [224].

As a result, patients with ME/CFS often show heightened immune responses owing to the combined effects of chronic stress with activated microglia [130,223] and increased HPA-axis sensitivity [224]. The HPA axis has been of great importance for the understanding of the pathophysiology of the disease, since the consequences of its alteration, such as hypocortisolism, have allowed us to understand the persistence of an altered immune status, the high risk of infections and the generation of humoral autoreactivity.
Although the metabolic sphere is not part of the aetiopathological pillars of the disease, it is clear that it is a physiological aspect compromised in patients with ME/CSF.

The dysregulation of the energetic metabolism can be understood as the tip of the iceberg, which will trigger the symptomatology experienced by the patient. However, the etiology of this metabolic imbalance in ME/CSF has not yet been understood, which is most likely because it is a pathological process that is the product of complex multisystemic interactions. Studies on metabolism and CFS suggest irregularities in energy metabolism, amino acid metabolism, nucleotide metabolism, nitrogen metabolism, hormone metabolism, and oxidative stress metabolism [228,229].

The overwhelming body of evidence suggests an oxidative environment with the minimal utilization of mitochondria for efficient energy production, leading to thoughts of some type of etiology in this organelle, but as we have seen previously, apparently the mitochondria are affected with the course of the disease [230]. As well as throughout the review, more studies are needed to understand which is the metabolic pathway that is first affected or which is the most altered in order to understand where to direct the etiological search in this complicated disease.

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