Chronic Fatigue Fatigue Syndrome
1. Q: When, where, and why were studies on CFS patients initiated?
A: 1987; Los Angeles County Hospital; As part of a program to develop clinical uses for the newly developed technology called "polymerase chain reaction" (PCR). I had helped in the development of PCR for human papillomaviruses, human cytomegalovirus (HCMV) and human JC virus (the cause of progressive multifocal leukoencephalopathy, PML). I knew of the suggested role of human herpesviruses-6 (HHV-6) in the Lake Tahoe CFS outbreak and wanted to see if PCR could detect HHV-6 in CFS patients. Zaki Salahuddin, then at the National Institutes of Health, Bethesda MD, kindly assisted by providing sequence data. Dr. Jay Goldstein provided blood samples from some of his CFS patients for HHV-6 testing.
2. Q: What were the initial findings?
A: Essentially negative results using the PCR assay for HHV-6 under conditions of high stringency (high specificity). Weak responses were, however, occasionally seen using conditions of reduced stringency. I had previously noted similar weak and atypical PCR responses in blood of several HIV infected patients being tested by PCR for human cytomegalovirus (HCMV). It was possible to reconfigure the PCR assays such that several sets of human HCMV reactive primers would amplify all of the then known human herpesviruses. Low level positive PCR responses were seen with several of Dr. Goldstein's patients as well as several HIV infected patients. These results were interpreted that the viral-like genes may be similar but different from those of known viruses.
3: Q: What did you do next?
A: I pursued the concept of using low stringency PCR to look for viral sequences in CFS and other patients. I also designed several sets of primers designed to react with regulatory genes of several viruses, including the "tax" gene of human T lymphotrophic virus (HTLV). By 1990, unequivocal positive PCR results were observed in several patients with CFS using a generic herpesvirus reactive primer set and/or an HTLV tax gene reactive primer set. In addition, positive findings were seen using both sets of primers in tests on cerebrospinal fluid (CSF) samples from two informative patients:
1. A 6-month-old baby (B.U.) born prematurely with clinical features of a viral infection (thrombocytopenia, large liver), but negative viral cultures. His CSF was devoid of any inflammatory cells, yet by PCR it tested strongly positive.
2. An 18-year-old boy (P.M.) with residual brain damage 3 years after an atypical encephalitis-like illness. His CSF also lacked any signs of inflammation.
In early 1990, I also received a request to do a PCR assay for JC virus on a brain biopsy from a school teacher (D.A.). She had developed difficulties in verbal and written communication, yet neurologically showed no major signs of brain damage. She did, however, have periventricular lesions on her MRI consistent with PML. The biopsy was negative by PCR for JC virus, but showed a weak positive herpesvirus- related PCR assay. Interestingly, the biopsy showed no evidence of inflammation. By electron microscopy, however, one could see viral-like particles in the cytoplasm, but not the nucleus, of vacuolated glial cells.
4: Q: What did you conclude?
A: At this stage, I was reasonably confident that the PCR assays were detecting atypical viruses with sufficient modifications as to not evoke the usual inflammatory responses associated with most viral infections. I submitted several grant applications for funding to study these "stealth" viruses without success.
5: Q: How did you proceed?
A: In some earlier studies, I had seen weak but inconsistent cytopathic effects (CPE) in various cell cultures of CFS patients's blood. The CPE was neither typical of that of HHV-6 using cord blood lymphocytes or that of HCMV using human fibroblasts. A renewed and more determined effort was made to culture blood from a CFS patient. A patient, D.W., had been briefly hospitalized in July 1990 with a mild encephalitis- like illness which followed an upper respiratory infection. Her CSF showed no evidence of inflammation. When I examined her, she was showing an incomplete recovery from the illness with evidence of fatigue and cognitive dysfunction. Several repeat PCR assays performed on her blood were positive using both a generic herpesvirus reactive primer set and the HTLV tax gene reactive primer set. . Her blood was then cultured on a variety of cell types. A delayed but striking cytopathic effect (CPE) developed on both human and animal cells. The infected cells became vacuolated with extensive syncytia. Repeat positive cultures were obtained in early 1991. The CPE could be transmitted to other cell cultures. Moreover, the cultures were strongly positive using the HTLV tax primers.
A similar strong positive culture was seen in the culture of CSF from a comotose patient (B.H.) with a four year history of bi-polar illness. This patient was considered to possibly have a Herpes simplex virus (HSV) encephalitis, and did receive Acyclovir. The lack of response to acyclovir and the fact that her CSF lacked the cellular response typical of HSV infection, changed the diagnosis to an unspecified drug overdose. Her culture was also positive by PCR using the HTLV tax primers.
The CPE seen in these two cultures was consistent with that described for human foamy viruses, a class of retroviruses called spumavirus (spuma= Latin for foam). The initial electron micrographs were also suggestive of a herpesvirus. I considered the possibility that we may have genes from a spumavirus inserted into a herpesvirus. The culture from B.H. was sent to the County Public Health Laboratory for help in identification. It was recognized as being unusual but simply dismissed as a viral contaminant.
6: Q: When did you first receive funding?
A: I discussed the results on both patients with Dr. Paul Cheney in early 1991. He visited the laboratory and subsequently supported funding of a proposal that I submitted to the CFIDS Association of America. Marc Iverson notified Dr. Walter Gunn of the CDC of our findings. In several telephone conference calls, I requested that Dr. Gunn send CDC personnel to see the cultures and visit with the two patients. Additional culture positive patients were also being found including several of Dr. Cheney's patients. Marc Iverson suggested it would help stimulate CDC interest if I mentioned the work at a San Francisco CFS meeting and follow it up at a scheduled CFS meeting to be held at CDC in September, 1991. Marc also arranged for coverage in Newsweek and the Wall Street Journal. I agreed with Marc's request especially since I had submitted papers for publication to the Lancet, Journal of the American Medical Association and to the annals of Internal Medicine.
7: Q: How was your work received?
A: My presentation at the San Francisco meeting was viewed as an attempt of the CFIDS Association to "upstage" their local group. The CDC meeting was also met with resistance.The 3 papers submitted for publication were rejected. The basic arguments against the work were expressed as follows:
1. There was not enough data to conclude anything yet and certainly one should not be talking to the media
2. Previous attempts by other investigators to culture viruses from CFS patients were unsuccessful.
3. We either had a contaminant or an activated passenger virus unrelated to the cause of CFS.
4. I was dealing with patients with atypical viral infections unrelated to what most people call CFS.
However, the work was continued with support from the CFIDS Association. The conventional approaches to virus characterization such as determining whether the genome was DNA or RNA, its density in high speed centrifugation studies and assays for viral associated polymerases were tried. None of these approaches could identify the virus and indeed they indicated that the virus had many atypical features. I was, however, able to begin to sequence two PCR products obtained from the viral cultures. One product was significantly related to, but still quite different from, HCMV. The origin of the other product was uncertain. The results were reported to the CFIDS Association and shared with various colleagues. My attempts to publish the data in Science and in Lancet were unsuccessful.
8: Q: Why was funding stopped?
A: The CFIDS Association was under considerable pressure to address several points listed above. Unable to comply with unanswerable demands and disliking the whole political flavor of what was occurring I backed away and all CFIDS Association funding was terminated.
9: Q: What do you think went wrong with the blinded study?
A: First, CFS is not a precise, well-defined clinical disorder and is unsuitable as an entity to evaluate a diagnostic test. Second, the controls used were i) children from the same town which experienced a CFS outbreak; ii) friends of CFS patients; and iii) adults working out at a local gym. I felt that research needed to go in the direction of better characterizing the viral isolates rather than being hung up in defending the concept that CFS is a discrete disorder with its own unique laboratory marker.
10: Q: What has happened since then?
A: Sequencing studies have shown that both of the initial viral isolates are related to African green monkey simian cytomegalovirus (SCMV). More interestingly, they suggest a somewhat unconventional view of considering fragmented viral genomes as the cause of cytopathology.The journal, "Clinical and Diagnostic Virology" published the sequence data showing the relatedness to SCMV. The journal, "Pathobiology" has published several papers including a description of the school teacher on whom the brain biopsy was performed in 1990 and on the comatose patient with a history of manic depression. Neither State nor Federal health authorities have chosen to investigate these patients or to respond to my reports of other severely ill, viral culture positive patients.
Two of the viral isolates were tested by Dr. Tom Glass for the ability to induce disease in cats. The results were quite striking and added considerable weight to the concept of a stealth viral encephalopathy. This work was published in "Pathobiology".
Many additional patients have been seen with positive viral cultures. The range of illness indicated a spectrum of neuropsychiatric manifestations. Evidence of apparent spread of infection within a family and to family pets was seen. In a few cases I received brain biopsy material from severely ill patients. The histology and electron microscopy corroborated the findings in the cats.
Several additional articles have been published and a web site established to help disseminate information regarding stealth viruses.
11: Q: How have these new findings been received?
A: The more recent findings have opened up another controversy since they indicate a stealth presentation of viruses from polio vaccines. Requests for financial assistance from FDA and CDC to pursue this issue, and even an appeal that these agencies disclose information concerning vaccine contamination, were denied. Scientifically, however, the notions of stealth viruses and of stealth viral encephalopathy is much more acceptable now than before. There are still skeptics, some of whom do not yet accept CFS as an illness or do not want CFS to be included in a spectrum of neuropsychiatric illnesses. Some believe that the viruses we are studying were manufactured for use in biological warfare. Fortunately, a number of caring people have provided sufficient financial assistance to allow continued studies.
12: Q: What approach would you like to take to pursue this work?
A: The concept behind the "Center for Complex Infectious Diseases" is to help bridge molecular virology with clinical neuropsychiatry. The work can proceed within the Center without undue outside interference. The planned research program is focused on developing molecular probes reactive with cells showing the stealth virus CPE. These probes will become the test of choice to diagnose stealth virus infection in patients with CFS and other neuropsychological illnesses. The ultimate question to be addressed is whether stealth viral infected patients will improve with anti-viral therapy. The cultures and the animal model provide valuable tools to help develop potential therapies. I would like to see a more vigorous response from those who are financially capable of supporting this type of research, both for themselves and for those who are financially and psychiatrically unable to do so.