Guest blog: Written, compiled and translated to English by Jørn Tore Haugen, Master of Science in Engineering, @jornt_h
Norwegian version: Noe er galt i ME-sykes blod
Myalgic Encephalomyelitis, also called CFS/ME, is a disease without a known biomarker.
Research by several research groups, independently of each other, has, however, made findings in plasma that may help to narrow the search for the cause of CFS/ME. Plasma from ME patients has shown to provoke aberrant responses, a form of hibernating, both in cells from ME patients and healthy controls. At the same time, plasma from healthy controls has eliminated this abnormal response in both cells from ME patients and healthy controls. In addition, several groups have shown that a key enzyme in energy metabolism, pyruvate dehydrogenase (PDH), is down-regulated.
Briefly about the blood
The blood consists of red (oxygen transport) and white (immune system) blood cells as well as platelets (stops bleeding) that flow around in the pale yellow fluid called plasma or blood plasma.
The Norwegian Medical Encyclopedia writes the following about plasma and serum: “The plasma consists of water and solutes, such as plasma proteins, amino acids, hormones, salts and metabolites. Plasma contains the soluble protein fibrinogen which can be converted to the insoluble fibrin. Fibrin forms a network that is suitable to stop bleeding. This is what happens in connection with coagulation. The blood fluid that remains after coagulation is called serum.»
Briefly about glycolysis and conversion to ATP
To understand the topics mentioned later, one should also have some insight into the breakdown of glucose and the formation of ATP (Adenosine triphosphate). ATP is particularly important and is the body’s fuel. The process takes place in three steps; glycolysis, the TCA cycle (tricarboxylic acid cycle, also known as the citric acid cycle and the Krebs’ cycle) and finally oxidative phosphorylation where most ATP molecules are made. The first two steps can be illustrated with the figure below which is taken from Chief Physician Øystein Fluge, Professor Olav Mella and Professor Karl Johan Tronstad‘s study published in 2016 (see below).
TCA cycle and oxidative phosphorylation take place inside the cells’ mitochondria (the energy powerhouse). The mitochondria are supplied with Acetyl-CoA, converted from glucose, and through a series of reactions, ATP, the body’s fuel, is eventually formed. An inhibition or down-regulation of the processes upstream of Acetyl-CoA will then naturally inhibit the production of ATP in the mitochondria and lead to energy deficiency.
Simplified, one can say that the figure shows the first parts of the breakdown of glucose (sugar) to the formation of energy to muscles and other organs. However, there are other processes that contribute to energy to the body, but glycolysis is central.
The key topic to note in figure 1) is PDH (Pyruvate dehydrogenase) and PDK (Pyruvate dehydrogenase kinase). Also note that in the case of downregulation of PDH (which can then be compared to a valve that is slightly closed), and which may be due to an upregulation of PDK, the process after the glycolysis will be “forced” in the direction of producing more lactate. Elevated lactate production in CFS/ME patients has also been shown in more than 20 studies with two-day cycling tests.
At the IACFS / ME 2020 Virtual Conference on August 21st 2020, Dr. Ina Katrine Nitschke Pettersen from the University of Bergen gave a talk on the subject «Defective Energy Metabolism in ME/CFS»
Quote from the british ME Association’s Conferene Report:
“They exposed healthy muscle cells to healthy control serum and ME/CFS patient serum for 6 days to see if something in the serum could change the metabolism in normal cells. They found increased overall mitochondrial respiration in the healthy muscle cells exposed to ME/CFS serum, compared to controls, with increased ATP production. They believe this represents some sort of overcompensation.”
(Mitochondrial respiration (simple explanation) = the conversion of Acetyl-CoA to ATP by the use of oxygen and the excretion of carbon dioxide. This is the TCA cycle, as mentioned above.)
“Glycolytic function was unchanged at rest, however, there was significantly increased lactate production under conditions of energetic strain (representing exertion). This may indicate the presence of a factor in the serum which is causing these metabolic changes in patients and they are now exploring these findings further.”
“The metabolite profile the researchers observed in ME/CFS patients suggests metabolic stress and the research team think that the metabolism is locked in a sort of “starvation mode” that we need to try to reverse. They believe that this may be triggered by some sort of immune response and that the mechanisms behind ME/ CFS involves immune-metabolic interactions.”
This is a continuation of the study published in 2016, where they showed that normal healthy muscle cells produced more lactate (lactic acid) and burned more oxygen when exposed to serum from CFS/ME patients, than in serum from healthy controls. This effect was particularly applicable when the muscle cells were exerted.
They believe the problem can be linked to a down-regulation of pyruvate dehydrogenase (PDH).
• Healthy muscle cells function normally in serum from healthy controlls as opposed to exposed to serum from CFS/ME patients
• Glycolysis problems associated with a down-regulation of Pyruvate dehydrogenase (PDH)
• The problem is linked to a factor in serum
Research Paper (Norway, Haukeland university hospital/University of Bergen)
- Charlotte Stephens, ME Association: The 2020 IACFS ME Conference Report
- Kavli trust (2016): New study on pathological mechanisms in ME from Bergen research group
- University of Bergen (2017): People who suffer from chronic fatigue have defects in their metabolism (Google translate)
- Cort Johnson, Health Rising (2020): Starving for Energy?
Ron Davis’ group
In a study published in April 2019, Dr. Rahim Esfandyarpour, Professor Ron Davis and several other researchers at Stanford University showed that immune cells and plasma from CFS/ME patients changed electrical impedance (about the same as electrical resistance) when exposed to external exertion (they added regular salt, the cells will then start to get rid of the salt).
Research Paper (USA, Stanford University)
Press release: Biomarker for chronic fatigue syndrome identified
Prior to the publication of this paper, the same group of researchers announced that they had used the same type of instrument (nanoneedle) and measured the electrical impedance using cells from CFS/ME-patients and healthy controls, in plasma from CFS/ME-patients and heathy controls.
The experiments including cells from CFS/ME-patients and healthy controls, in plasma from patients, gave a signal. While the experiments including cells from CFS/ME-patients and healthy controls, in plasma from healthy controls, did not give any signal.
Both the study and the data presented in advance of the study indicate that the problem is related to the CFS/ME-patients’ plasma, while the good news is that cells from CFS/ME-patients behave normally in the plasma of healthy controls. This should indicate that this is a reversible process and that CFS/ME will be able to be treated or cured in the future.
In 2017, Professor Ron Davis also stated that he saw problems related to glycolysis and mentioned Pyruvate dehydrogenase kinase (PDK).
- Cells from CFS/ME-patients and healthy controls, gave signal in plasma from CFS/ME-patients
- Cells from CFS/ME-patients and healthy did not give a signal in plasma from healthy controls
- Glycolysis problems associated with Pyruvate dehydrogenase kinase (PDK)
- Simon McGraths, ME/CFS Research Review (2019): Latest from Ron Davis: More evidence of “something in the blood”
- David Tuller, Virology blog (2019): Trial By Error: Simon McGrath on Ron Davis on “something in the blood”
- Forskning.no (2019): Blood tests distinguished ME patients from healthy ones (Google Translate)
Prusty and Naviaux’s groups
Dr. Bhupesh K Prusty is a somewhat unorthodox researcher in the way he communicates. He uses Twitter relatively actively and from time to time there is some news in the form of new tweets.
In April 2020, he published a study in collaboration with, among others, Professor Robert Naviaux and Professor Carmen Scheibenbogen where the main findings are associated with down-regulation of PDH. They write:
“The downregulation of a protein involved called pyruvate dehydrogenase – a core enzyme in regulating glycolysis – was of particular importance, as infected immune cells need to get their energy from glycolysis (ATP production that does not use oxygen), instead of mitochondrial oxidative phosphorylation (ATP production that uses oxygen).”
Research Paper (Germany / USA)
Prusty on Twitter
A couple of months before the paper was published, Prusty wrote a longer Twitter-thread. One of the tweets where:
“We hypothesized that a factor/molecule in serum can cause mitochondrial dysfunction. So we took serum from patients, isolated that molecule out of serum and then tested it on cells in the absence of other cellular components from serum and could show the same effect”
Or said in other words. When they tested only this molecule (factor) on the cells, they found the same dysfunctional effect in the mitochondria as when testing “sick serum” in its entirety.
The same factor isolated from serum from healthy controls did not have the same effect.
He then elaborates that the factor is not a virus but a cellular component, and he confirms that the cells release this factor in response to a virus that has harmful effects on the host (mine and your cells).
Read the entire Twitter thread from February 2020 by clicking on the tweet below:
On July 21st, 2020, he also tweeted that he was working on a test for a potential biomarker.
On October 9th, 2020, he followed up with new Twitter messages about testing a new diagnostic platform, and that he hoped to have the result ready as a Christmas present this year.
- They isolated a molecule (factor) out of serum from patients and tested this on cells in the absence of other cellular components from serum. This showed the same dysfunctional effect in the cells as shown with “sick serum” as a whole.
- The same molecule (factor) isolated from serum from healthy controls does not have the same dysfunctional effect on the cells.
- Glycolysis problems associated with a down-regulation of Pyruvate dehydrogenase (PDH).
- Other: The hypothesis is that reactivation of the herpes virus HHV6 leads to an antiviral activity in the blood, which affects the immune system and mitochondria, which in turn leads to immunity and reduced energy production. See tweet from April 7th 2020 below:
This may indicate that Prusty is on the track of what in the serum is causing the disease.
- Bhupesh Prusty, lecture/video (2020): Mitochondrial dysfunction in ME/CFS
- Cort Johnson, Health Rising (2020): Explaining ME/CFS?
- ME Association (2020): Is mystery factor in plasma causing viral immunity in ME/CFS?
- Dr. Theodore Henderson, Psychiatry Advisor (2020): Chronic Fatigue Syndrome, Viruses, and the Innate Immune System
Karl Morten’s group
In a lecture at the ‘ME/CFS Support (Auckland)’ conference in December 2018, Professor Karl Morten, Oxford University, presented findings from experiments in which they had exposed muscle cells from healthy controls to plasma from healthy controls and CFS/ME-patients.
They found that plasma from healthy controls did not cause any change in oxygen levels (blue and green dots overlap in the figure below). In contrast, plasma from CFS/ME-patients caused the oxygen level to drop (red dots). This indicates that the mitochondria work harder (a similar result as Fluge/Mella/Tronstad has shown).
- Plasma from healthy controls did not cause any change in oxygen levels in healthy muscle cells
- Plasma from CFS/ME-patients caused oxygen levels to drop in the same type of muscle cells from healthy controls
Carmen Scheibenbogen’s group
In a “proof of concept” study published in July 2020, four out of five participating patients had a rapid improvement in a number of clinical symptoms after undergoing immunoadsorption (IA) – a technique in which the blood is purified.
Research Paper (Germany, University Hospital Charité)
It is also known that Professor Scheibenbogen has subsequently stated that plasmapheresis can be an equally relevant technique to use, such as immunoadsorption.
Note, in the study by Prusty and Naviaux mentioned above, Scheibenbogen was a co-author.
- Symptom relief in 80% of patients immunoadsorption (IA) (purifying blood)
Jonas Bergquist’s group
In July 2020, Professor Jonas Bergquist at Uppsala University published a new paper in which he looked at plasma and spinal fluid. He made no findings in the spinal fluid, but found significantly upregulated autoantibodies in plasma, which can be found in autoimmune conditions. In a statement at publication of the paper, the research group also told that preliminary studies using immunoadsorption and/or plasmapheresis to remove antibodies have shown a positive effect in a sub-group of CFS/ME-patients.
Immunoadsorption and plasmapheresis are methods used to purify plasma. The experiments by Bergquist and Scheibenbogen thus show, with a different approach, the same as the experiments which have been done in laboratories having cells exposed to plasma from CFS/ME-patients and healthy controls, respectively.
- Immunoadsorption and/or plasmapheresis have shown a positive effect in a subgroup of CFS / ME patients.
Research Paper (Sweden, Uppsala University)
Bergquist and Scheibenbogen have collaborated on this study.
- Open Medicine Foundation (2020): Autoimmunity and Autoantibodies in ME/CFS
Julia L. Newton’s group
In October 2020, Professor Julia L. Newton‘s group published a study that is not directly associated with attempts to switch plasma between healthy and CFS / ME patients, but they write:
«Results show that CFS skeletal muscle cells are unable to utilise glucose to the same extent as healthy control cells. CFS skeletal muscle cells were shown to oxidise galactose and fatty acids normally, indicating that the bioenergetic dysfunction lies upstream of the TCA cycle» (see Figure 1 above).
«This could potentially include defects to pyruvate dehydrogenase complex (PDH), pyruvate dehydrogenase kinase (PDK), or mitochondrial protein carriers (Fig. 6). This fits with a study which used a PDK inhibitor in an open-label proof-of-principle trial and a study by Fluge et al.  looking at PDH dysregulation in CFS blood samples».
Here Newton is referring to a defect in CFS/ME-patients related to PDH and/or PDK – the same as Fluge/Mella/Tronstad’s group, Ron Davis’ group, and Prusty and Naviaux’s groups have indicated (see references above).
When she writes “This fits with a study which used a PDK inhibitor in an open-label proof-of-principle trial” she refers to the study “Treating patients suffering from myalgic encephalopathy / chronic fatigue syndrome (ME / CFS) with sodium dichloroacetate: An open-label, proof-of-principle pilot trial” by the Belgian Frank Comhaire, Ghent University Hospital, and his experiment with sodium dichloroacetic acid – a PDK inhibitor.
Note that Julia L. Newton also over the past five years has been involved in at least six more studies associated with energy metabolism, two of which deal with glucose metabolism (2015 and 2018).
Research Paper (UK, University of Newcastle)
- Potential defects in Pyruvate dehydrogenase complex (PDH), Pyruvate dehydrogenase kinase (PDK) or mitochondrial protein carriers.
- ME Research UK (2020): Use of glucose for energy production in muscle cells from patients with ME/CFS
- Cort Johnson, Health Rising (2020): Study Suggests Energy Production Problems May Be Everywhere in Chronic Fatigue Syndrome (ME/CFS)
- Phoenix Rising debatt-forum: Substrate utilisation of cultured skeletal muscle cells in patients with CFS
Two other groups
- Alain Moreau’s group
The NIH conference “Accelerating Research on ME/CFS” took place in USA on April 4th and 5th 2019.
At the conference Professor Alain Moreau gave a speech were he described a bioimpedance test they have done (where the measurement parameter is similar to Ron Davis’ measurement parameter in the nanoneede tests). He stated that the test “partially confirms what Dr. Ron Davis has previously shown – that there is something in plasma, and we completely agree.” In that sense, he is in line with the groups discussed above.
In November 2020, Alain Moreau and his group published the paper “Profile of circulating microRNAs in myalgic encephalomyelitis and their relation to symptom severity, and disease pathophysiology.”
In this study, Moreau used a cuff, similar to the one used around the upper arm when measuring the blood pressure, to provoke PEM in a gentle way. (PEM is the abbreviation for Post Exertional Malaise – the hale mark symptom of ME/CFS).
The cuff was blown up and down (around the arm) for 90 minutes. Before and after testing, blood samples were taken from both CFS/ME-patients and healthy controls. Plasma analyzes showed a distinct difference in 11 microRNA molecules, suggested as a possible biomarker. The differences in the microRNA profiles of the patients could also be associated with symptoms and severity of the disease.
Research paper (Canada, University of Montreal)
- Possible biomarker
- Open Medicine Foundation (2019): NIH Accelerating Research on ME / CFS Recordings
- The Scientist (2020): Blood MicroRNA Patterns Linked to Chronic Fatigue Syndrome
- Very Well Health (2020): New Test for Chronic Fatigue Syndrome Could Help COVID-19 Patients
Professor Alain Moreau is dedicated to CFS/ME research, but it is not known whether he has performed experiments with plasma from healthy controls and CFS/ME-patients, and exchanged such plasma between the groups. Moreau is the Head of the research center at the University of Montreal, which is part of the ME/CFS Collaborative Research Centers and funded by the Open Medicine Foundation.
2. Mady Hornig, Ian Lipkin and others
The analysis is based on identifying the types of proteins they found in the participants plasma. In the paper, they write; “Our findings are consistent with a significant association of ME/CFS with immune dysregulation and highlight the potential use of the plasma proteome as a source of biomarkers for disease”.
Research paper (USA, Columbia University)
- Possible biomarker
- There are at least seven research groups that link the problems of CFS/ME-patients with fatigue and lack of energy to the blood plasma (energy in physical understanding and proper meaning, not in a figurative sense related to spiritualism and other alternative understandings).
- In experiments with cells from both healthy controls and CFS/ME-patients exposed to plasma from healthy controls and CFS/ME-patients, respectively, only plasma from CFS/ME-patients give an abnormal condition in cells from both healthy controls and CFS/ME-patients.
- Attempts to expose cells to plasma from CFS/ME-patients, and then “wash out” the plasma and expose the same cells to plasma from healthy controls, have shown that these cells go from a state of hibernation to “awakening”. This proves that the condition is reversible, in other words the condition will be possible to treat and/or cure. In addition, it indicates that the problem is associated with plasma in CFS/ME-patients.
- By “purifying” plasma in patients, a reduction in symptoms has been shown. This is a continuation of testing of cells and plasma in the laboratory.
- There are at least four research groups that link the mentioned problems to down-regulation of pyruvate dehydrogenase (PDH) or the regulation of this enzyme in the form of up-regulated pyruvate dehydrogenase kinase (PDK).
- Several groups use the term “factor” about something in plasma that causes the findings they report.
- Dr. Bhupesh Prusty is probably working to identify this “factor”.
Several research groups have shown that switching plasma from CFS/ME patients or healthy controls can cause a disease reaction or a normal reaction in the cells, respectively. Likewise has immuneadsorption and/or plasmapheresis (purifying plasma) provided relief in symptoms. Several groups talk in this context about a “factor” in plasma as a cause.
In some of the same studies, several of the groups point to pyruvate dehydrogenase kinase (PDK, upregulation) and/or pyruvate dehydrogenase complex (PDH, downregulation) as a key problem, which results in increased lactate (lactic acid). These findings are supported by the fact that there are more than 20 studies showing abnormal lactate and oxygen values in two-day cycling tests (ergospirometry, CPET).
Is it a “factor” in plasma which causes:
- an upregulation of pyruvate dehydrogenase kinase (PDK)?
- which in turn leads to a down-regulation of pyruvate dehydrogenase complex (PDH)?
- which in turn “forces” energy metabolism into anaerobic and less efficient energy metabolism, with increased lactate production, which is the problem?
And what is this “factor”? Is it what Alain Moreau or Mady Hornig and Ian Lipkin describe in their studies? Or is it something else?
Maybe we’ll know more when Bhupesh Prusty publishes new studies? On December 21, 2020, he shared a number of tweets, and this is one of them:
Bhupesh Prusty is optimistic and brings hope for the future!
PS! This entire blog is inspired by and a continuation of Simon McGrath’s blog ME/CFS Research Review, and the text “Something in the blood.”
Any errors and misunderstandings in the text are solely my own.
Written and compiled by Jørn Tore Haugen, Master of Science in Engineering, Twitter: @jornt_h
Edited and revised by blog owner Sissel Sunde, Twitter: @sissel777
Edited: Section “Briefly about the glucolysis and conversion to ATP” has been revised on monday 04.01.2021 after input from Aslaug Angelsen.