CHRONICFATIGUESYNDROMESTUDIESONCLINICAL…慢性疲勞綜合征的臨床的研究…課件

1、PROTEA biopharmaPress ConferenceRitz Hotel London, Thursday 28th of May 2009Unravelling the Origin ofMyalgic Encephalomyelitis:Gastrointestinal Dysfunction, Production of Neurotoxinsand Environmental ExposureProf. Kenny De Meirleir, M.D, Ph.DChris Roelant, Ph.DMarc Frmont, Ph.D第1頁(yè)，共24頁(yè)。Myalgic encep

2、halomyelitis: A highly prevalent debilitating disease Persistent, debilitating fatigue associated with numerous physical and neurocognitive symptomsDisease severity can range from moderate to extremely severe: patients bedridden for years, totally caregiver dependent Prevalence estimates: 0,3 to 0,6

3、%; one million patients in the USA, two million patients in EuropeThis may just be the tip of the iceberg High socio-economic costCost to the society estimated as approximately $16 billion in the USA, 20 billion in Europe第2頁(yè)，共24頁(yè)。 Patients usually present with multiple intestinal symptoms including:

4、NauseaAbdominal painPoor appetiteAbnormal bowel motilityGastric refluxBloating Inflammation of the gastrointestinal tract Marked alteration of the intestinal microbial floraIntestinal disorders in ME patients第3頁(yè)，共24頁(yè)。 Enterococcus and Streptococcus species are strongly over-represented in ME patient

5、s :OrganismsControlME patientsp-valueE.coli1.0 x 1084.26 x 107p=0.98Enterococcus spp.5.0 x 1063.5 x 107p0.001Streptococcus spp.8.9 x 1049.8 x 107p0.001Henry Butt, University of MelbourneAlterations of intestinal microflora (aerobes)第4頁(yè)，共24頁(yè)。 Among anaerobic bacteria, Prevotella is the most consisten

6、tly overgrown bacteria :Henry Butt, University of MelbourneOrganismsControlME patientsp-valueBacteroides spp.3.2 x 10111.6 x 1011p=0.39Prevotella spp.1.0 X 1089.0 x 109p 0.001Bifidobacterium spp.6.0 x 1085.5 x 109p=0.001Lactobacillus spp.2.7 x 1071.8 x 108p=0.002Alterations of intestinal microflora

7、(anaerobes)第5頁(yè)，共24頁(yè)。Henry Butt, University of MelbourneSymptoms r and p-valuesHeadacher=.17, p0.01Arm painr=.20, p0.003Shoulder painr=.15, p0.04Myalgiar=.20, p0.003Palpitationsr=.16, p0.02Sleep disturbancer=.20, p0.004 Enterococcus spp. counts correlate with symptom expression :Bacterial overgrowth

8、correlates with symptoms severity第6頁(yè)，共24頁(yè)。Henry Butt, University of Melbourne Streptococcus spp. counts correlate with symptom expression :Symptoms r and p-valuesPost Exertional fatiguer=.15, p0.03Photophobiar=.14, p0.04Mind going blankr=.17, p0.01Cervical gland lymphodyniar=.14 p0.04Palpitationsr=.

9、15, p0.03Dizziness/Faintnessr=.14, p0.05Bacterial overgrowth correlates with symptoms severity第7頁(yè)，共24頁(yè)。 Hydrogen sulfide (H2S) has important physiological functions.H2S is produced by the cells and is an important gaseous signal molecule, involved in regulation of blood pressure, neurotransmission,

10、muscle relaxation and regulation of inflammationHydrogen sulfide produced by bacteria works as a potent toxin for the body .but exogeneous exposure can be extremely toxicIn excess, H2S acts as a mitochondrial poison. It can directly inhibit enzymes involved in the cellular production of energy. H2S

11、also interferes with oxygen transport by blocking hemoglobin in the red blood cells.Enterococcus, Streptococcus, Prevotella are strong H2S producers第8頁(yè)，共24頁(yè)。E. coliStreptENTEROFungiBacteriaGutGut barrierH2SMold(metals)MSSCH3CH3PRPCPRPDXOther gaseousmediators : NO. CO.Cumulative effects of H2S and he

12、avy metals MMMMSSCH3CH3H2SMitochondriaATPCell第9頁(yè)，共24頁(yè)。Heavy metals interfere directly with energy production OxidaseCu2+HSSSSHQ10NADHKrebs cycleO2.-NO.ExtracellularPlasmamembraneIntracellularATP+ONOO.R-S-SSAdapted from James Morr 2019 J Inorg Biochem 100 2140-2149第10頁(yè)，共24頁(yè)。Genetic and environmental

13、factors contribute to aberrant protein conformationPRPCPRPDXGeneticAcquiredEnvironmentalMutationsHeavy MetalsPRP DX第11頁(yè)，共24頁(yè)。Abnormal conformation can be transmitted from one cell to anotherCellMetalsCellCellPRCPRPDX第12頁(yè)，共24頁(yè)。I“Pre-ME”IIModerate diseaseIIISevere diseaseDysfunctionsAbnormal faecal te

14、st, high H2SAbnormal faecal test, high H2S, exposure to heavy metalsAbnormal faecal test, high H2S, exposure to heavy metals that has caused aberrant protein conformation (APD)SymptomsNo fatigue, possible gastro-intestinal symptoms. Low VO2, slow recovery.May be asymptomaticFatigue, gastro-intestina

15、l symptomsStrong fatigue, multiple symptomsTreatmentRestore the gut: probioticsRestore the gut: probiotics, enterocoated antibiotics.Metal chelation, Zinc supplementationDifficult. Gut restoration, metal chelation. Treatment of associated dysfunctions (opportunistic infections). Treatment of APD is

16、still experimentalIncreasing immune dysregulations (depressed T and NK cells, Th17 activation,opportunistic infections)Disease severity in ME is associated with different physiological dysfunctions第13頁(yè)，共24頁(yè)。Immune alterations resulting from intestinal dysfunctionNave T cellsTH1cellsTH2cellsTH17cells

17、Protection againstintracellular pathogens(viruses, bacteria)Protection againstextracellular pathogens(parasites, bacteria)Local immunity(mucosa, skin)Protection againstfungi, bacteriaIL-12TGF-b + IL-6IL-4IFN-gDysbiosis causes a decreaseof CD8+ cells and TH1 immunityTH1 downregulation allowsincreased

18、 TH2 and TH17第14頁(yè)，共24頁(yè)。Consequences of altered immunity TH1 decrease favors the development of opportunistic viral infectionsHHV-6, Epstein-Barr, parvovirus B19, enterovirusesare found in ME patients. Gastro-intestinal mucosais a major site of infection TH2 increase favors the development of allergi

19、es TH17 increase promotes inflammation, autoimmunity, blood-brain barrier disruptionGenetic background plays a role in TH17 upregulationPolymorphisms of IL-17F, IL-6, TLR4, TGF-b genesare associated with ME and other intestinal diseases(Crohns disease, UC, IBS)第15頁(yè)，共24頁(yè)。Patient evaluation Urine test

20、 for marker associated with H2S production Intestinal microflora evaluation Heavy metals analysis Presence of proteins with abnormal conformation Assays evaluating subsequent immune dysfunctions (immune dysregulations, opportunistic infections.)第16頁(yè)，共24頁(yè)。A marker associated with H2S production can b

21、e measured with a simple urine test1. Collect urine2. Open tube containing test reagent3. Add a few drops of urine to the test reagent4. Mix by shaking gently. Wait for two minutes5. Observe color changes. Dark color = positive sampleNegative orPre-MEModeratediseaseSeveredisease第17頁(yè)，共24頁(yè)。A specific

22、microbiological assay can determine gut microflora populations Investigation of the microbial flora of the intestinal tract Quantifies major aerobic and anaerobic bacterial groups and yeast Focuses on dysbiosis (imbalance of the intestinal ecosytem) rather than digestive analysis to ascertain gut in

23、tegrity Challenge: keep anaerobic bacteria viable for analysis- Validated oxygen-free, temperature controlled collection and shipping system第18頁(yè)，共24頁(yè)。Microbiological assay : sample result Patient presents increased Streptococcus, Enterococcus, and Prevotella第19頁(yè)，共24頁(yè)。Heavy metal analysis : sample result Patient presents mercury and nickel intoxication第20頁(yè)，共24頁(yè)。Abnormal prot