Sunday, January 19, 2014

Dr. Carmen Scheibenbogen, Berlin Charite

A most remarkable study on ME/CFS was published January 15, 2014.

The study, by Dr. Carmen Scheibenbogen and her team at Berlin Charite, can be found here

From the study:

“By comparing memory B- and T-cell responses of CFS patients with healthy EBV-infected subjects, we observed a profound deficiency in EBV-specific B- and T-cell memory response in the majority of CFS patients resembling the deficiency of EBV memory responses described in autoimmune diseases [56] and chronic HIV infection [57], [58], [59].”

The following comments are by anciendaze, who writes commentary on various forums, including Phoenix Rising, a forum that provides terrific information. Anciendaze writes with great knowledge, insight and clarity.

“This looks like the real thing. The highly specific immune impairment certainly looks like a virus defending itself. A complete lack of patient IFN-gamma response to the EBNA-1 challenge is striking. Latent replication allows the virus to benefit from clonal expansion of infected cells in response to immune challenges from unrelated pathogens. This is one feature I felt pretty sure about earlier, and only retroviruses seemed to have the required ability.”

“The parallels with HIV and HCV will make it much harder to ignore. Contrasts with SLE should illuminate the murky subject of autoimmune disease. We still don't know what initiates the process, since most ME/CFS patients were exposed to EBV long before the appearance of symptoms.”

I got the heads up on this research when I heard Dr. Scheibenbogen give a talk at the Invest in ME conference in London in May 2013

Three quarters through her half-hour talk I was struck by what she was saying. Dr. Scheibenbogen and her group looked at the normal EBV antibodies (IgG, IgM, EBNA) of their patients. In doing so they were surprised to find that 10% of these patients had low EBNA. The team took this to be another secondary indication of immune abnormality in a subset of CFS patients and they decided to look further at all the patients. They did not attach a particular meaning to this lower EBNA beyond that it was one more hint of immune abnormality in CFS patients (specifically in regard to EBV). She expressed her belief that this abnormality just represents the tip of an iceberg. Based on this finding, they developed a much more sensitive assay to access B cell antibody response, by looking for the response against more than 2000 peptide fragments of the whole EBV virus itself. From the almost 100 proteins of the EBV virus itself, they took the most relevant and cut the proteins in pieces and tested them. This sophisticated testing - looking for an abnormal response to EBV - found in the first round of assays that 2/3 of CFS patients had a different response than controls. They have continued to work with larger number including patients from Norway as well as using other diseases as controls. This altered EBV specific response is their basis for developing a diagnostic test for a subset of CFS patients. Her lab is collaborating with a company in Berlin in developing a diagnostic test for a subset of ME/CFS. (Patients in Germany are referred to as CFS).

In this talk Dr. Scheibenbogen indicated that her ideas about ME/CFS parallel those of Dr. Amolak Bansal, an immunologist in London, who also gave a lecture in 2013 at Invest in ME. She also gave a significant nod to the work of Dr. Oystein Fluge and Dr. Olav Mella.

Dr. Scheibenbogen and two of her colleagues attended a one-day pre-conference meeting of researchers on May 29, 2013. Thirty some researchers met to discuss a particular topic or focus for research. Last year the subject was Infections, Immunity and ME. The year before the research conference was on Autoimmunity. Of course getting researchers together to talk is a splendid idea. A good number of them come from outside the field of ME/CFS.

Invest in ME produces a modestly priced DVD of their annual conference. I suggest that those interested readers buy this DVD and view these lectures. The entire thrust of this conference and pre-conference private research discussions are quite extraordinary - and are driving towards a consolidation of research into this illness.

This conference is guided by Richard and Pia Simpson. Their nine or ten year struggle to focus research is really paying off with increasingly wide ranging connections with the sole intent of getting at this illness. I cannot say enough positive things about Invest in ME and urge American clinicians and researchers to attend this conference. I have witnessed myself the exchanges that happen at the pre-conference dinner, and on the conference day itself. This conference is the place to be if you want to encounter cutting edge research about this illness.

Regarding the publication of this paper yesterday one wonders what Dr. Ron Glaser will think of it? Are we going to have a confluence of ideas here - or the more typical disconnect that we associate with ME/CFS research? Certainly the researchers in Australia – Dr. Sonya Marshall-Gradisnik and Dr. Don Staines – will have their eye on this continuing research, as will Dr. Fluge and Mella. All of these researchers have made presentations at Invest in ME for the last few years and have participated in the pre-conference day discussions.

Further comments by anciendaze, to whom I am greatly indebted.

“This paper looks like the real thing. The immune impairment they describe is highly specific to EBV. One of the surprises in the main text is that none of the CFS patients they tested with a challenge involving a polypeptide from EBNA-1 produced an IFN-gamma response. This fits perfectly with the hypothesis of latent replication. Their results concerning deficits of polyfunctional immune cells with three different functions helps explain earlier mixed results concerning EBV. Researchers were looking for much less specific immune impairment.”

“Please note that the full text of the referenced paper describes tests for EBV infection which go a great deal beyond common clinical lab results. They also report that tests showed a great deal of latent replication must be taking place. Common assumptions in testing for EBV are based on active infections and antibody response to them. Few labs test for DNA of latent virus in immune cells. This paper specifically reports that certain evidence of RNA, produced by active infections, was absent or reduced. It also shows a crippled response via IFN-gamma. Under these circumstances it is unreasonable to say that it can't apply to you because you don't have unusual EBV results from standard clinical labs.”

“PCR testing, both qPCR and RTPCR, is part of the suite of tests used, but only part. They also used multiparameter flow cytometry to count immune cells with multiple markers. Even studies doing clinical flow cytometry have typically been limited to sorting cells by a single marker. (Note the disclaimer at the bottom of the page about the research instrument.) This would prevent them from detecting the specific deficits of polyfunctional immune cells found here. Beyond that they used ELISA and stimulated cell culture immunoassays. It's all there in the text.”

“This is the kind of battery of modern research techniques which has so often been absent in studies of ME/CFS. I'd say they really examined their early data and were guided by it in choosing that immune challenge with EBNA-1. This is not an example of confirmation bias behind a single favorite hypothesis.

 A further comment from anciendaze:

"Normally, we think of a DNA virus like Epstein-Barr Virus (EBV) as being either active or latent, and assume it isn't doing much of anything while latent. EBV actually has several latent states. Latent phase 0 describes the least active state, which pretty well matches what we assume. There are also latent phases I, II, III. During these states it is possible for viral replication to take place. Active phase replication is typically lytic, with host cells being destroyed to release virions. Replication during latent phases need not destroy the host cell.

This has a major implication in the context of clonal expansion of immune cells. In this case stimulated immune cells divide by the normal process of mitosis, producing 2, 4, 8... daughter cells. This can lead to millions of cells producing a powerful response to an antigen detected by a small number of cells.

EBV infected cells have one or more episomes inserted inside the nuclear membrane. These are just plasmids, loops of DNA, floating around loose, not inserted in chromosomes. If clonal expansion just distributed a few episomes among many daughter cells, most of these cells would not be infected. However, if the virus is able to replicate viral DNA without destroying the host cell, it then has the ability to infect all cells resulting from clonal expansion. This has the potential to produce large numbers of infected cells without most of the indications of viral infection.

In order to exploit clonal expansion EBV doesn't even need to produce virions. It only needs to trigger replication of DNA strands, something host cell machinery does naturally during mitosis.

We know that retroviruses do exploit clonal expansion through passive replication of inserted provirus. (This has been a major problem in the fight against HIV.) We did not know this was often going on in a very common human virus which does not insert genes in chromosomes. What we did know was that most ME/CFS patients continue to show polyclonal expansion (of B cells in particular) while the disease state persists, but we could not find a single pathogen responsible. Immune response seems to be confused and often misdirected. Some patients do show autoantibodies (ANA, ATA, ACA); many do not, at least by current standards used for autoimmune diseases. Considering the limited understanding of those diseases, it may be time for a reevaluation.

In the past we have frequently heard that evidence of EBV infection was inconsistent or absent in ME/CFS patients. This research shows that conventional lab results give a very misleading picture, and offers some reason why. Furthermore, the evidence available now paints a picture of cells with viral DNA and nuclear antigens, but reduced or absent RNA from lytic replication, cytokines and antibodies. It really appears that this virus is crippling specific immune response to itself.

This has implications for a wide range of clinical tests, and for a number of diseases besides ME/CFS."