Pre-Illness Data reveals Differences in Multiple Metabolites and Metabolic Pathways in Those Who Do and Do Not Recover from IM, 2022, Jason et al

[Simon M]

Pre-Illness Data reveals Differences in Multiple Metabolites and Metabolic Pathways in Those Who Do and Do Not Recover from Infectious mononucleosis

https://pubs.rsc.org/en/Content/ArticleLanding/2022/MO/D2MO00124A

Leonard Jason, Karl Conroy, Jacob Furst, Karthik Vasan and Ben Katz

Abstract
Metabolic pathways related to energy production, amino acids, nucleotides, nitrogen, lipids, and neurotransmitters in myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) may contribute to the pathophysiology of ME/CFS.

4,501 Northwestern University college students were enrolled in a prospective, longitudinal study. We collected data before illness, during Infectious Mononucleosis (IM), and at a 6 month follow-up for those who recovered versus (N=18) versus those who went onto develop ME/CFS 6 months later (N=18).

Examining pre-illness blood samples, we found significant detectable metabolite differences between participants fated to develop severe ME/CFS following IM versus recovered controls. We identified glutathione metabolism, nucleotide metabolism, and the TCA cycle (among others) as potentially dysregulated pathways. The pathways that differed between cases and controls are essential for proliferating cells, particularly during a pro-inflammatory immune response. Performing a series of binary logistic regressions using a leave-one-out cross-validation (LOOCV), our models correctly classified the severe ME/CFS group and recovered controls with an accuracy of 97.2%, sensitivity of 94.4%, and specificity of 100.0%.

These changes are consistent with the elevations in pro-inflammatory cytokines that we have reported for patients fated to develop severe ME/CFS 6 months after IM.

 

[Andy]

Going by recent papers from Jason, 'severe ME/CFS' just means that the person meets two or more ME selection criteria.

 

[Peter T]

Great to see these results.

I had hoped there would be people somewhere doing the same in relation to Covid 19, there was such an opportunity to look at a whole population in the early stages of the pandemic and then follow up over several years.

 

[Midnattsol]

Great to see these results.

I had hoped there would be people somewhere doing the same in relation to Covid 19, there was such an opportunity to look at a whole population in the early stages of the pandemic and then follow up over several years.

It might be still possible, at least in Norway some of our long-running cohort studies have pre-pandemic blood available for metabolomics. The one I'm most familiar with has focused mostly on lipids though, with blood sampled in 2006-2008.

 

[butter.]

This will turn out to b a very important paper. I can already see how people sleep on it and its vast implications. Mitochondrial dysfunction predates what people consider their trigger.

 

[voner]

I found a copy of the paper at:

https://0x0.st/oaF3.pdf

 

[voner]

Going by recent papers from Jason, 'severe ME/CFS' just means that the person meets two or more ME selection criteria.

here is an quote from the paper:

we selected three major ones including the Fukuda et al. criteria,(15) the Canadian Consensus Criteria,(16) and the Institute of Medicine criteria(17). Those who met more than one case definition (i.e., the Fukuda and either the Canadian and/or Institute of Medicine criteria) were defined as having severe ME/CFS.

 

[Andy]

here is an quote from the paper:

we selected three major ones including the Fukuda et al. criteria,(15) the Canadian Consensus Criteria,(16) and the Institute of Medicine criteria(17). Those who met more than one case definition (i.e., the Fukuda and either the Canadian and/or Institute of Medicine criteria) were defined as having severe ME/CFS.

Thanks, as I suspected. I am really concerned about this rebranding of the term 'severe ME'. For patients, and many other people, severe ME denotes a certain, serious, level of impairment; if this attempt to redefine it catches on I can easily see it used by anybody who wants to downplay the severity of a patients suffering.

"Severe ME? That just means you meet two selection criteria, it doesn't mean you can't work or need those benefit payments."

And what happens if you are a severe (by the 'old' definition) patient who happens to only meet one definition? Are you then reclassified as moderate? mild? even less deserving?

 

[Trish]

I agree it's a serious problem. Perhaps we need to write to the research team.

 

[Mij]

I'm curious, is MS defined as serve, moderate or mild?

I personally prefer relapsing-remitting because we can go from mild, moderate or severe within a week.

 

[Hutan]

It's open access if you sign up. I think the settings on my computer prevented me from accessing the study via Voner's link.

Gender skew - not as substantial as is often quoted.

The severe ME/CFS group was majority female (61.1%; male=38.9%), majority White/Caucasian and Latinx (52.9%; 29.4%; Black/African American=11.8%; Asian or Pacific Islander=5.9%)

Edit - it isn't clear to me from the paper if the 18 subjects with 'severe ME/CFS' are all of the people who developed 'severe ME/CFS'.



This previous paper provides more details about the study (link is to the S4ME thread)
(11). Jason LA, Cotler J, Islam MF, Sunnquist M, Katz BZ. Risks for developing ME/CFS in college students following infectious mononucleosis: a prospective cohort study. Clin Infect Dis 2021;73:e3740–9.

 

[Hutan]

Significant differences in peak area value between the severe ME/CFS and recovered groups were observed for eight metabolites (see Table 1). For spermine and carbomyl phosphate, participants who went on to develop severe ME/CFS 6 months following IM had lower values at baseline than controls who recovered from IM; for fructose-1,6/2,6-biphosphate (F-1,6/2,6-DP), spermidine, ATP-dGTP, glutathione disulfide, citrate, and cytidine 5'-diphosphate (CDP), participants who went on to develop severe ME/CFS 6 months following IM had higher values at baseline than controls who recovered from IM.

 

[Hutan]

We identified glutathione metabolism, nucleotide metabolism, the TCA cycle, polyamine metabolism (spermine, spermidine), glycolysis (F-1,6/2,6-DP), and urea cycle (carbamoyl phosphate) as potentially dysregulated pathways. These pathways are essential for proliferating cells, particularly during a pro-inflammatory immune response, and are thus consistent with irregularities in cytokines that we have reported in this10 and a previous19 cohort. Alterations in these pathways are also potentially consistent with previous reports of changes in energy production, nucleotide metabolism, TCA metabolism, and reactive oxygen species pathways in adults with ME/CFS.

It will be interesting to see if DecodeME finds any genetic issues relating to these metabolites and pathways.

 

[Hutan]

Re spermine and spermidine:
This study found that the ME/CFS group had lower spermine, but higher spermidine. It's a very interesting finding.

Searching the forum, the only mention of spermine and spermidine is a paper about treatment of Covid-19. The two molecules seem to have a role in autophagy.

Targeting of autophagic pathways by exogenous administration of the polyamines spermidine and spermine, the selective AKT1 inhibitor MK-2206, and the BECN1-stabilizing anthelmintic drug niclosamide inhibit SARS-CoV-2 propagation in vitro with IC50 values of 136.7, 7.67, 0.11, and 0.13 μM, respectively. Autophagy-inducing compounds reduce SARS-CoV-2 propagation in primary human lung cells and intestinal organoids emphasizing their potential as treatment options against COVID-19.

There's a 2014 paper about the function of spermine and spermidine:

Polyamines are present in virtually all living cells and a wide variety of polyamines are formed in nature according to the species. Mammals produce only spermine, spermidine, and their precursor, the diamine putrescine (Fig. 1A). These polyamines play important roles in many cellular processes including the regulation of transcription and translation, control of the activity of ion channels, modulation of kinase activities, effects on the cell cycle, protection from oxidative damage, the maintenance of membrane structure/function, and contributing to nucleic acid structure and stability.

This 2014 paper reported that, unlike for spermidine 'there is no known function that is exclusive to spermine', although it is assumed to be important for something, given there is gene for spermine synthase (which produces spermine from spermidine). It sounds as though the effectiveness of the human synthase gene is variable.

It is noteworthy that human SpmSyn has a low activity compared to other well-characterized aminopropyltransferases and its kcat value can be increased 10-fold by mutations altering the active site

Low spermine creates issues with oxidative stress.

A number of mammalian cell lines that lack SpmSyn activity and have no detectable spermine have been grown in culture. These include embryonic stem cells from mouse strain 129/SvJ 12, primary skin fibroblasts from Gy mice 13, and immortalized embryonic fibroblasts 14. These cells grew normally but showed differences in response to drugs, oxidative stress, and UV radiation. With a few exceptions, these results are in agreement with studies in which specific inhibitors of SpmSyn were used to reduce spermine content (see refs. 15, 16 and references therein).

At the organism level, mutations in the spermine synthase gene can be lethal, and can cause severe problems in animals including Snyder-Robinson syndrome.

The 2104 paper gives ratios for spermine to spermidine in lymphoblasts of healthy controls and of people with the harmful mutation. It would be very interesting to know what ratio is in people with ME/CFS. Looking at Table 1 above, any change in ratio looks to be subtle, certainly compared with the differences in the ratios of people with Snyder-Robinson Syndrome. I'm not seeing a lot of similarities between ME/CFS and the syndrome:

It is an X-linked intellectual disability syndrome combined with a number of other clinical features including osteoporosis, kyphoscoliosis, speech abnormalities, asthenic habitus with diminished muscle mass, hypotonia, facial dysmorphism, a mild short stature, and a high incidence of seizures.

Degree of disability isn't well related to the spermine:spermidine ratio, so there are other things going on. Also, the spermine synthase gene seems to be on the X chromosome - meaning that women should be protected somewhat from harmful mutations, which doesn't fit with the gender ratio of ME/CFS.

Polyamines play an important role in the protection from reactive oxygen species ... Polyamines have been shown to act as free radical scavengers, to quench singlet molecular oxygen and shield phage and microbial DNA from oxidative damage 42-44. They also mediate defense from oxidative damage by stimulating the synthesis of protective gene products such as superoxide dismutase, heat shock proteins, and cell cycle regulators 44, 45. Although spermidine has some activity in this respect, spermine is considerably more effective.

Regulation of ion channels

Several types of ion channels that play critical roles in mammalian physiology are profoundly influenced by polyamines. These include: the inwardly-rectifying potassium (Kir) channels, which control membrane potential and potassium homeostasis in many cell types; glutamate receptors including N-methyl-D-aspartate (NMDA), α-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid (AMPA), and kainate receptors that mediate excitatory synaptic transmission in the mammalian brain; and other related channels affecting intracellular calcium signaling, Na+ transport, and some connexin-linked gap junctions

The polyamine-medicated effects on Kir and NMDA channels are fairly well understood at the molecular level. Detailed structural and biophysical studies of the binding of polyamines to these proteins have been published. These include work on the specificity for individual polyamines of both binding and the strength of the resulting effect. Although both spermidine and spermine can be active in these respects they differ in potency and affinity with spermine being considerably more effective. Thus, the correct spermine:spermidine ratio may be necessary for appropriate physiological activity and increased levels of spermidine unable to compensate for the loss of spermine.

Altered activity of brain glutamate receptors in response to the reduction or loss of spermine may be the source of the intellectual impairment in SRS patients and the behavioral changes in Gy mice. The NMDA receptors, a subtype of glutamate receptors, are critical for induction of synaptic plasticity, needed for memory and learning. Their activity is profoundly influenced by extracellular spermine, which is more effective than other polyamines 4. The brain has the highest level of SpmSyn in all the tissues examined 25. Although the extent to which this contributes to extracellular levels of spermine is not yet well understood, it has been shown recently that spermine increases glial intercellular communication by interacting with glial gap junctions. The glial syncitium propagates spermine through these gap junctions and increase astrocytic coupling 50.

Other classes of glutamate receptors such as AMPA and kainate receptors are also regulated by spermine. Kainate receptors are involved in synaptic plasticity and have been linked to epilepsy-like seizure activity and alterations in their activity could contribute to the tendency to seizures reported in some SRS patients

 

[Midnattsol]

It might be still possible, at least in Norway some of our long-running cohort studies have pre-pandemic blood available for metabolomics. The one I'm most familiar with has focused mostly on lipids though, with blood sampled in 2006-2008.

For this study data was also collected in 2019, but as far as I know metabolomics has not been done. I think it is planned, but when it's only recently been done for the last data collection it could take a while. In response to the pandemic participants were also asked to contribute to an extra set of questionnaires and samples, and they started collecting this extra data from sept. 2021 and it is still ongoing (the cohort is a representative sample from a whole county, and to collect data a team travels around and stays for a number of days at various locations). I don't know if the other longitudinal cohort studies in Norway are doing something similar, they have many things in common but also some differences.

 

[mariovitali]

A copy of the paper can be found here : https://0x0.st/oaF3.pdf

 

[Simon M]

I've got mixed feelings about this study (I've only read the abstract and the comments here, especially from Hutan).

Strengths
1. It's a prospective study.

The great thing about this study is that it collected Baseline data before people developed glandular fever, and then recovered or developed ME CFS.

2. The study used strict (Bonferroni) statistical correction for multiple comparisons. That decreases the chances that these are chance findings.

3. The metabolic differences are consistent with (though don't prove) the pro-inflammatory cytokine changes previously found in the same cohort.

Weaknesses
1. It's a small study, with only 18 people in each group (recovered/developed "severe" ME/CFS).

2. As many others have pointed out, there's no good rationale for the study's definition of "severe" as meeting two different criteria. I'm pretty sure this was not specified in the study design. So I'm guessing it popped up when they started data analysis, which is a little concerning.

It would be interesting to see results for the full recovered versus ME/CFS cohorts.

3. Are the metabolic differences clinically significant?

Looking at table 1, the absolute differences in mean metabolite levels are rather small. Is there any evidence that these have any clinical meaning?

Although spermine does play a role in a pro-inflammatory response, like spermidine, it also plays an essential role in all animal and plant cells. It's a leap to say that these small differences are connected to a difference in cytokine responsiveness and an ability to fight infections.

That's the nature of metabolites: the role of many of them isn't well understood and they often have multiple roles. That gives researchers a lot of scope to link metabolites to many different biological processes. Whether or not those links are important in the real world.

 

[Forbin]

It seems like a large sample size (4,501), so you’d think that the fact that half of the college age participants who came down with infectious mononucleosis (18/36) went on to develop ME/CFS would be a headline in and of itself.

Even if it were confined to “college age” participants, if that proportion were confirmed, you’d think it would be a pretty big deal.

[Not that I’m suggesting EBV is the sole cause of ME/CFS].

 

[rvallee]

It seems like a large sample size (4,501), so you’d think that the fact that half of the college age participants who came down with infectious mononucleosis (18/36) went on to develop ME/CFS would be a headline in and of itself.

Somehow news that MS is largely caused by mono barely made the news either. It did get some coverage but considering that this is identifying the cause, you'd think there would be major interest. So no surprise this doesn't get much interest.

I'm not sure what's going on as this should be major news and maybe lots are happening in secret, behind closed doors, but even in medical news and forums this seems to have gotten very little interest and isn't moving the needle much on anything, as if the idea is so unappealing that most don't want it to be true.

There's something about medicine and rejecting the germ theory of disease that just continues to plod along, like they have to believe that illness must exactly match injury, if it doesn't, ignore. Only a severe infection can cause severe illness, mild infections must only cause minor, temporary, problems. It's really hard to understand other than from the endless obsession with blaming everything on psychology instead.

 

[LarsSG]

It seems like a large sample size (4,501), so you’d think that the fact that half of the college age participants who came down with infectious mononucleosis (18/36) went on to develop ME/CFS would be a headline in and of itself.

The two groups of 18 are just the "severe" ME patients and 18 matched controls selected for this specific metabolic investigation. Their previous paper showed 23% meeting any one of the three criteria and 8% more than one criteria at six months. Still a lot, but not 50%.