PROCEEDINGS OF THE LATVIAN ACADEMY OF SCIENCES. Section B, Vol. 70 (2016), No. 4 (703), pp. 205–210. DOI: 10.1515/prolas-2016-0032 POSSIBLE RELATION OF ROSEOLOVIRUS INFECTION WITH FIBROMYALGIA Svetlana Èapenko1,#, Marija Mihailova2, Santa Rasa1, Angelika Krûmiòa3, Zane Zazerska1, Inâra Logina2, and Modra Murovska1 1 Augusts Kirhenðteins Institute of Microbiology and Virology, Rîga Stradiòð University, Râtsupîtes iela 5, Rîga, LV-1067, LATVIA 2 Department of Neurology and Neurosurgery, Rîga Stradiòð University, Dzirciema iela 16, Rîga, LV-1007, LATVIA 3 Depatment of Infectology and Dermatology, Rîga Stradiòð University, Dzirciema iela 16, Rîga, LV-1007, LATVIA # Corresponding author; [email protected] Contributed by Modra Murovska Fibromyalgia (FM) is a chronic widespread pain disorder that impacts 0.5%–7% of the general population worldwide. The aetiology and pathogenesis of the disease are still unknown. Human herpesvirus-6 and -7 belong to the family Herpesviridae, subfamily Betaherpesvirinae, and genus Roseolovirus and are immunomodulating viruses potentially pathogenic to the nervous system. Presence of anti-HHV-6 and -HHV-7 antibodies and viral genomic sequences, viral loads, HHV-6 variant-specificity, and TNF-a level were studied in 41 FM patients and 50 healthy individuals us- ing polymerase chain reactions, restriction endonuclease analysis and ELISA. There was no dif- ference in the presence of anti-HHV-6 and anti-HHV-7 IgG class antibodies between FM patients and control group individuals. Viral sequences were found in 80.5% of FM patients and in 62.0% of controls. Significantly higher rate of concurrent HHV-6 and HHV-7 infection and higher viral loads in peripheral blood were detected in FM patients compared to the control group individuals. Plasma viremia was detected only in FM patients. Significantly higher TNF-a levels were detected in virus positive FM patients. From all positive cases only in two FM patients HHV-6A was re- vealed. Significantly higher detection frequency of concurrent HHV-6 and HHV-7 infection, simul- taneous HHV-6 and HHV-7 activation, higher viral loads and TNF-a expression levels in primary FM patients than in control group individuals indicate the potential involvement of Roseoloviruses in development of this disorder. Key words: fibromyalgia, human herpesvirus-6, human herpesvirus-7, infection, molecular diag- nostic. INTRODUCTION College of Rheumatology (ACR) diagnostic criteria. Ac- cording to these criteria, FM diagnosis may be stated if the Fibromyalgia (FM) is a common, chronic widespread pain patient has chronic widespread pain and 11 or more positive disorder that is estimated to impact 0.5% to 7% of the gen- of a possible 18 tender points on physical examination, fa- eral population worldwide (Balon and Wise, 2015). The tigue, sleep disorders, headaches, memory or concentration epidemiology of FM in Latvia has not been studied in de- problems, mood disturbances, and stiffness. tail. In 2010, ACR FM diagnostic criteria were supplemented Host individuals diagnosed in clinics are young or middle with new details (Hakim et al., 2010; Wolfe et al., 2011) aged; however, population surveys suggest that frequency that include the estimation of the widespread pain index of disease increases with age as well as symptom severity (WPI) and the symptoms of severity (SS) score scale. The and worsening of life quality (Ballantyne et al., 2010; SS scale score is the sum of the severity of three symptoms Branco et al., 2010; Jiao et al., 2014; Balon and Wise, (fatigue, waking unrefreshed, cognitive symptoms) plus the 2015). Females suffer from FM eight times more frequently extent of somatic symptoms in general. than males (Albin et al., 2008). The aetiology and pathogenesis of FM are still unknown. The term fibromyalgia appeared relatively recently, in 1976. This disease is probably of multi-factorial nature, since Diagnosis is clinical and is based on the 1990 American many patients have onset of the clinical phenotype of FM Proc. Latvian Acad. Sci., Section B, Vol. 70 (2016), No. 4. 205 following a specific trigger. There are many open questions may significantly affect the generation and functionality of with few or controversial answers. Such triggers can include effective immune responses (Lusso et al., 2006). Lusso various viral infections, such as hepatitis C (Kozanoglu et (2006) and Atedzoe et al. (1999) have shown that both of al., 2003; Mohammad et al., 2012; Rogal et al., 2015), par- the viruses increase the production of inflammatory cytoki- vovirus B19 (Cassisi et al., 2011), HIV (Kole et al., 2013; nes. Wiffen et al., 2013; Fox and Walker-Bone, 2015), and Ep- stein-Barr virus (Buchwald et al., 1987). 55% of patients The aim of this study was to: 1) examine the presence of identify a “flu-like” or viral infection as a precursor to the HHV-6 and/or HHV-7 genomic sequences in whole periph- onset of symptoms, but the role of viral infection in FM de- eral blood and cell free plasma DNA samples from patients velopment has not been estimated. with FM and practically healthy persons (control group); 2) determine HHV-6 variant-specificity in whole peripheral One of the major theories is that cytokines may have a role blood DNA; 3) compare HHV-6 and HHV-7 load in periph- in both the aetiology of the FM and in the intensity of core eral blood samples from the FM patients and control per- symptoms (Menzies and Lion, 2010). Goldberg (1989) sug- sons; 4) compare pro-inflammatory cytokine TNF-a plasma gests that the viruses might directly invade central nervous level in patients with FM and control group individuals. system or are capable of activating cytokines which may in turn cause severe myalgia, fatigue, and neurocognitive dis- turbances. MATERIALS AND METHODS The study was performed during 2013–2015. Clinical and According to the current state of knowledge the origin of virological (including serology and molecular biology) fea- the pain in FM and variety of FM symptoms are triggered tures were examined in the 41 patients with clinical diag- by peripheral as well as central mechanisms (Sprott, 2011; nose of primary FM and 50 practically healthy persons. The Clauw et al., 2011). primary FM diagnosis was established by a neurologist or Up to date, there are no data on the role of HHV-6 and algologist in the out-patients’ clinic of Pauls Stradiòð Clini- HHV-7 infection in the FM development. Human herpes- cal University Hospital. None of the 41 patients with pri- virus-6 (HHV-6) and -7 (HHV-7) belong to the Herpesviri- mary diagnosed FM were hospitalised in the Neurology and dae family, Betaherpesvirinae subfamily, Roseolovirus ge- Neurosurgery Hospital. According to case and drug history, nus (Berneman et al., 1992) and are ubiquitous (more than 10 of the 41 patients had not received prior medical treat- 90% of adults have antibodies to the viruses) immunomodu- ment; none of the patients had received steroids or statins, lating, and potentially pathogenic to the nervous system. In but pain relief medication only. 2012, the International Committee on Taxonomy of Viruses Diagnosis was setup based on ACR 2010 diagnostic criteria re-classified HHV-6 as separate viruses HHV-6A and for the FM (Widespread pain index (WPI) is equal or more HHV-6B based on biocharacteristics regarding cell tropism than 7, symptom severity scale score (SS) — equal or more and pathological implications (Ablashi et al., 2014). After than 5, duration of symptoms at least three months, and the primary infection, the viruses establish a state of life-long patients do not have a disorder that would otherwise explain subclinical persistence or latency in CNS (Yoshikawa and the pain). In our FM patients group the mean WPI was 12.7 Asano, 2000) and can be reactivated in cases of immuno- ± 3.24 (minimal score 4 and maximal score 18), and mean suppression. HHV-6A, HHV-6B and HHV-7 DNA are of- SS scale score — 8.1 ± 1.4 (minimal score 6 and maximal ten found in brain tissue from healthy individuals (without score 11). Mean duration of symptoms was 7.9 ± 6.2 years. pathological changes in the brain) (Chan et al., 2001; Yao et Exclusion criteria were previously known polyneuropathy, al., 2010). cervical radiculopathy clinical symptoms, diabetes mellitus, HHV-6 infection has been associated with neurologic pa- rheumatoid arthritis, liver diseases, myalgic encephalomye- thologies such as multiple sclerosis (Ablashi et al., 2000; litis/chronic fatigue syndrome, and myocardial infarction. Chapenko et al., 2003; Nora-Krukle et al., 2011), which is Of 41 individuals with FM, 40 were females and one was associated with inflammation, mesial temporal lobe epi- male (mean age 51, range: 24–71) and from 50 control lepsy in the absence of inflammation in brain tissue (Donati group individuals, 40 were females and 10 were males et al., 2003; Fotheringham et al., 2007; Niehusmann et al., (mean age 48, range: 35–78). Peripheral blood samples 2010), myalgic encephalomyelitis/chronic fatigue syndrome from the patients with FM were received from the Neurol- (Ablashi et al., 2000; Chapenko et al., 2006; Bansal et al., ogy and Neurosurgery Department, Rîga Stradiòð Univer- 2012; Chapenko et al., 2012) and with different neurologi- sity. cal complications after allogeneic hematopoietic stem cell transplantation (Bhanushali et al., 2013) and solid organ The study was approved by the Ethics Committee of Rîga transplantations (Chapenko et al., 2009; Massih and Ra- Stradiòð University, and all of the participants gave in- zonable, 2009). The association of HHV-7 infection with formed consent before the examination. these disorders is not sufficiently studied. HHV-6 and HHV-7 serology. Testing for antibodies HHV-6 and HHV-7 infection profoundly modifies the pro- against HHV-6 and HHV-7 in cell free blood plasma sam- file of cytokine and chemokine production, which in turn ples was carried out using HHV-6 IgG ELISA kits (Panbio, 206 Proc.