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Scientistspotlight ScientistSpotlight Mady Hornig: The battle against Chronic Fatigue Syndrome Introduction Chronic Fatigue Syndrome, known medically as myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS), is a debilitating disease that by some estimates affects as many as 4.5 million individuals in the US alone. Symptoms, which include extreme fatigue, difficulty concentrating, headaches, and muscle pain, typically begin in the aftermath of a viral-type infection and often last for years. There are no lab tests for ME/CFS. The disorder remains a mysterious and sometimes controversial illness. It is not yet part of any medical school curriculum; physicians as well as the general public have long disagreed about whether it qualifies as a biological disease or a psychological disorder. As a consequence, people with ME/CFS often feel stigmatized. A sharper understanding of ME/CFS has emerged. Researchers at the Center for Infection and Immunity (CII) at Columbia University’s Mailman School of Public Health recently published research findings that identify distinct immune changes in patients with ME/CFS. Showing distinct phases in the trajectory of the disease, this work provides perhaps the strongest support yet that chronic fatigue syndrome is a biological illness, not a psychological disorder. Mady Hornig, MD, Director of Translational Research at CII and an associate professor of Epidemiology at Columbia’s Mailman School, is the lead author of the research, published in Science Advances. Affymetrix: Why is ME/CFS getting more attention these days? Hornig: Renewed interest in studying ME/CFS began heating up around 2010 with a suggestion that one or more viruses might be implicated in the disease. Even though we eventually ruled out the two suspected viruses, the momentum had begun and new initiatives were funded. One of the key groups is the Chronic Fatigue Initiative (CFI), formed in 2010 by the Hutchins Family Foundation. “Technological advances have enabled us to discover many more immune molecules and their signaling pathways and to understand how essential these are to brain development and brain function. Improvements in the sensitivity and reliability of multiplexed immunoassays such as the ProcartaPlex® Immunoassay from Affymetrix.” The CFI-funded work has several prongs, including recruitment of the cohort, establishment of a unique sample biobank, and creation of a database that links clinical data to biological samples in the biobank. These components of the CFI form a powerful resource for both ongoing and future research. CII, directed by W. Ian Lipkin, MD, was a logical fit with the goals of the CFI given our longstanding focus Mady Hornig, MA, MD, is Director of Translational Research in the Center for Infection and Associate Professor of Epidemiology at the Mailman School of Public Health at Columbia University. A physician-scientist, she is internationally recognized for her animal model work and clinical research in human cohorts on the role of microbial, metabolomic, immune, and toxicologic factors in brain disorders, including autism, schizophrenia, attention- deficit/hyperactivity disorder, obsessive-compulsive disorder, mood disorders, and myalgic encephalomyelitis/chronic fatigue syndrome. She was the lead author of a paper published in Science Advances in February 2015, describing distinct sets of immune biomarkers in blood across the disease trajectory of ME/ CFS, firmly supporting the concept that the disorder has a biological basis, as well as of a second paper defining immune signatures in the cerebrospinal fluid of ME/CFS patients that was published in Molecular Psychiatry in March 2015. 1 “Through immune profiling of blood samples from patients diagnosed with ME/CFS, we have detected distinct changes in these immune molecules, identifying patterns in the immune system that have important relationships with different phases of the disease.” on pathogen discovery and immune and infectious connections to brain diseases. I have been working in this area for well over 20 years, studying disorders such as depression, bipolar disorder, and schizophrenia, as well as several brain disorders that first manifest in childhood and in which immune disturbances appear to play a role, including autism, attention-deficit/hyperactivity disorder (ADHD), and PANDAS (Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal infection), an acute autoimmune disorder that follows strep throat in some vulnerable children, manifesting as acute obsessive-compulsive disorder (OCD)-like features, tics, and eating problems. Technological advances have enabled us to discover many more immune molecules and their signaling pathways and to understand how essential these are to brain development and brain function. Improvements in the sensitivity and reliability of multiplexed immunoassays such as the ProcartaPlex® Immunoassay from Affymetrix are accelerating our ability to discover new biological markers of disease based on samples that are easily accessible, such as peripheral blood. A few decades ago it would have taken more blood than could be drawn at one sitting to produce some of the information we can now acquire using even just a few drops of the blood collected into a standard blood tube. These new capabilities at the lab bench herald exciting new directions for research into brain disorders like ME/CFS, OCD, ADHD, depression, mild cognitive impairment, Alzheimer’s, and even autism. Affymetrix: Can you tell us more about the relationship between ME/CFS and the immune system? Hornig: Brain-immune interactions are at the heart of the disease processes we study. Disturbances among the many microbes that inhabit our intestinal tracts can disrupt the balance of the so-called metabolome. The metabolome comprises the bacterial and host metabolites present in blood and other biological samples, including amino acids, neurotransmitters, short chain fatty acids, and a host of other inflammatory and neuroactive molecules. Distortions in an individual’s metabolome can skew their immune molecules, some of which interact with brain receptors, including those located in key regions of the brain’s stress-response circuitry like the hypothalamic- pituitary-adrenal axis. Through immune profiling of blood samples from patients diagnosed with ME/CFS, we have detected distinct changes in these immune molecules, identifying patterns in the immune system that have important relationships with different phases of the disease. Different mechanisms appear to be active in different stages of the illness; where patients lie along their disease trajectory may help predict which treatments will be most effective for them. The study we published in February 2015 used immunoassay testing methods to determine the levels of 51 immune biomarkers in blood plasma samples collected through two multicenter studies. These two studies represented a total of 298 ME/CFS patients and 348 healthy controls. In patients who had the disease three years or less, we found specific patterns that were not present in controls or in patients who had had the disease for more than three years. Patients at three years or less had increased amounts of many different cytokines; notably, even small increases in interferon gamma, an immune molecule linked to the fatigue that follows infection with viruses like Epstein-Barr virus, the cause of infectious mononucleosis, were more common in the early phases of illness. These discoveries are closely linked to the improved sensitivity of our immunoassays; even small increases in immune molecules such as interferon gamma could be detected. A month after our first study came out, we published a second paper in the journal Molecular Psychiatry that reported our discovery of another unique pattern of immune molecules among people with ME/CFS, this time in their cerebrospinal fluid. The group of ME/CFS patients we examined in this study were largely further along in the course of their illness; not unexpectedly, the immune patterns we found in cerebrospinal fluid for these patients were quite similar to those we found in the plasma of long-duration ME/CFS patients. This discovery provides insights into the basis for cognitive dysfunction in ME/CFS—frequently described by patients as “brain fog”—as well as offering new hope for improvements in diagnosis and treatment. Our finding that the immune changes observed in the peripheral blood are also present in the central nervous system (as represented by cerebrospinal fluid) supports the concept that this illness is a systemic one, and may help to explain the presence of symptoms in both peripheral parts of the body and the brain. Affymetrix: What do you make of your findings that there are different stages of the disease? Hornig: ME/CFS patients often report first getting sick with illnesses that are time-limited, like infectious mononucleosis, with swollen glands in the head and neck, sore throat, and fever; however, unlike most patients with infectious mononucleosis, they never fully recover. Our research suggests that in these patients, the immune response to the initial infection-like illness may get stuck in “high gear,” with cytokine levels remaining very high for around three years. After the three-year mark, the levels of most of the cytokines we studied begin to drop, with the immune system beginning to show evidence of exhaustion. Rapid detection of these immune changes may both facilitate early diagnosis and open up unique opportunities for initiation of treatments
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