Metab Brain Dis

DOI 10.1007/s11011-012-9324-8

REVIEW ARTICLE

A neuro-immune model of Myalgic Encephalomyelitis/Chronic

fatigue syndrome
Gerwyn Morris & Michael Maes

Received: 18 April 2012 / Accepted: 7 June 2012

# Springer Science+Business Media, LLC 2012

Abstract This paper proposes a neuro-immune model for may activate microglia via the vagus nerve. Elevated proin-
Myalgic Encephalomyelitis/Chronic fatigue syndrome (ME/ flammatory cytokines together with raised O&NS conspire
CFS). A wide range of immunological and neurological to produce mitochondrial damage. The subsequent ATP
abnormalities have been reported in people suffering from deficit together with inflammation and O&NS are responsi-
ME/CFS. They include abnormalities in proinflammatory ble for the landmark symptoms of ME/CFS, including post-
cytokines, raised production of nuclear factor-κB, mito- exertional malaise. Raised levels of O&NS subsequently
chondrial dysfunctions, autoimmune responses, autonomic cause progressive elevation of autoimmune activity facili-
disturbances and brain pathology. Raised levels of oxidative tated by molecular mimicry, bystander activation or epitope
and nitrosative stress (O&NS), together with reduced levels spreading. These processes provoke central nervous system
of antioxidants are indicative of an immuno-inflammatory (CNS) activation in an attempt to restore immune homeo-
pathology. A number of different pathogens have been statsis. This model proposes that the antagonistic activities
reported either as triggering or maintaining factors. Our of the CNS response to peripheral inflammation, O&NS and
model proposes that initial infection and immune activation chronic immune activation are responsible for the remitting-
caused by a number of possible pathogens leads to a state of relapsing nature of ME/CFS. Leads for future research are
chronic peripheral immune activation driven by activated suggested based on this neuro-immune model.
O&NS pathways that lead to progressive damage of self
epitopes even when the initial infection has been cleared. Keywords Chronic fatigue syndrome . Inflammation .
Subsequent activation of autoreactive T cells conspiring Cytokines . Depression . Tryptophan . Oxidative and
with O&NS pathways cause further damage and provoke nitrosative stress . Mitochondria . Autoimmune
chronic activation of immuno-inflammatory pathways. The
subsequent upregulation of proinflammatory compounds Abbreviations
ME Myalgic Encephalomyelitis
G. Morris WHO World Health Organization
Tir Na Nog, CFS Chronic fatigue syndrome
Pembrey,
PICs Pro-inflammatory cytokines
Llanelli, UK
TNFα Tumor necrosis factor
M. Maes IL-6 Interleukin-6
Maes Clinics @ TRIA, NK Natural killer
Bangkok, Thailand
O&NS Oxidative and nitrosative stress
M. Maes (*) NF-κB Nuclear factor κB
Piyavate Hospital, 2-5A 2′-5′-oligoadenylate
998 Rimklongsamsen Road, RNaseL 2-5A-dependent ribonuclease L
Bangkok 10310, Thailand
PKR Protein kinase R
e-mail: [email protected]
URL: http://scholar.google.co.th/citations? COX-2 Cyclo-oxygenase 2
hl0en&user01wzMZ7UAAAAJ&oi0sra IFNγ Interferon γ
 Metab Brain Dis

Th T helper subset (Maes et al. 2012a). Moreover, the data show that
TGF-β1 Transforming growth factor post-exertional malaise is a key component of ME and
Treg T regulatory differentiates ME from CFS (Maes et al. 2012a). Thus, the
ATP Adenosine triphosphate diagnosis of ME, CFS and ME/CFS refer to different con-
LPS Lipopolysaccharide cepts, ranging from chronic fatigue together with physio-
TLR Toll-like receptor somatic symptoms (Fukuda et al. 1994), to a symptom
BBB Blood brain barrier complex where post-exertional malaise is a key factor (Maes
SPECT Single-photon emission computed tomography et al. 2012a). Patients with ME display the unique charac-
PET Positron emission tomography teristic of producing a range of objectively measurable ab-
T MRI Tesla magnetic-resonance imaging normal physiological responses to exercise and a global
HPA Hypothalamic-pituitary-adrenal worsening of symptoms following even trivial increases in
MS Multiple sclerosis cognitive or physical activity (De Becker et al. 2000; Nijs et
IDO 2,3-dioxygenase al. 2005; Lane et al. 1998). Obviously these differences in
TRYCAT Tryptophan catabolite diagnostic classifications and criteria have blurred the
NMDA N-methyl-D-aspartate results of scientific research. In this paper we will use the
NADP Nicotinamide adenine dinucleotide phosphate term ME/CFS, since most research until now has been
STAT3 Signal Transducer and Activator performed on ME/CFS and not on ME as defined recently
of Transcription 3 (Maes et al. 2012a; Carruthers et al. 2011).
Foxp3 Forkhead box P3 Recently an explanatory model has been developed in
PBMCs Peripheral blood mononuclear cells support of the WHO’s classification that considers ME to be
SNPs Single nucleotide polymorphisms a neuro-immune disorder (Maes 2009; Maes and Twisk
2010; Maes et al. 2012b). This model provides considerable
evidence that the pathophysiology of ME/CFS is associated
with immuno-inflammatory pathways, which lead to neuro-
Introduction logical aberrations, including behavioral responses, and
neuro-endocrine, autonomic and brain dysfunctions.
Myalgic Encephalomyelitis (ME) has been described in the The presence of raised levels of the pro-inflammatory cyto-
medical literature since the ‘30s. Characteristics of ME are kines (PICs), tumor necrosis factor (TNF)α, interleukin-6 (IL-
post-exertional malaise, chronic fatigue, autonomic symp- 6) and IL-1β, is a consistent finding in patients with ME/CFS
toms, hyperalgesia, malaise, neurocognitive dysfunctions, who show signs of a chronically activated and highly disregu-
and a chronic and relapsing-remitting course. The World lated immune system. These include the presence of autoim-
Health Organization (WHO) acknowledges ME as a disease mune responses, loss of natural killer (NK) function and raised
of the nervous system (World Health Organization 1992). levels of the anti-inflammatory cytokines. Studies investigating
Much later, in the ‘80s and ‘90s, the diagnosis of chronic the pathophysiology of ME/CFS have consistently revealed a
fatigue syndrome (CFS) was introduced. The definition of wide range of aberrations in oxidative and nitrosative stress
CFS is primarily based upon the presence of chronic fatigue (O&NS) pathways and lowered antioxidant defenses. Perhaps
lasting more than 6 months. According to a commonly used unsurprisingly then evidence of mitochondrial damage has
diagnostic classification of CFS (Fukuda et al. 1994), chron- been reported in patients with ME/CFS. Studies have reported
ic fatigue must be accompanied by four or more of the activation of intracellular signaling molecules, e.g. nuclear
following symptoms: substantial impairment in short-term factor κB (NF-κB) and the 2′-5′-oligoadenylate (2-5A)/2-5A-
memory or concentration; sore throat; tender lymph nodes; dependent ribonuclease L (RNaseL) and the protein kinase R
muscle pain; multi-joint pain without swelling or redness; (PKR) pathways. A new immuno-inflammatory pathway in
headache of a new type, pattern or severity; unrefreshing ME/CFS that may cause neuro-immune dysfunctions and even
sleep; and post-exertional malaise lasting more than 24 h. neurological disease is bacterial translocation.
ME and CFS are therefore different diagnostic concepts Here we propose a key role for changes in immuno-
(Maes et al. 2012a; Twisk and Maes 2009). inflammatory pathways and resultant neuro-inflammation, in
In an attempt to define a more homogenous patient pop- conjunction with aberrations in O&NS pathways, in produc-
ulation, a panel of ME/CFS experts has published consensus ing the wide range of symptoms reported and abnormalities
criteria for ME (Carruthers et al. 2011). Using multivariate identified in people with ME/CFS. This paper proposes that an
statistical analyses, Maes et al. (2012a) showed that the interaction between an activated immune system, O&NS, and
diagnosis of CFS according to Fukuda’s criteria (Fukuda et mitochondrial damage, explains the symptoms of ME/CFS.
al. 1994) defines a heterogeneous population of individuals This is an area of active research and much needs to be
with chronic fatigue, of whom individuals with ME are a confirmed by new results. As such there are gaps, which we
Metab Brain Dis

have filled with established knowledge on immune and neuro- CD8+T cells (Landay et al. 1991), and higher percentages of
immune mechanisms and directions for future research. CD8+T cells and higher numbers of CD8+T cell class 11
activation markers (Klimas et al. 1990). We have reviewed
that a Th2 response with increased levels of IL-4 or IL-5 may
Pathophysiological findings in ME/CFS occur in part of the patients (Maes et al. 2012b; Fletcher et al.
2009). Other studies show signs of immunosuppression, in-
Immuno-inflammatory pathways in ME/CFS cluding lowered NK cell activity and raised levels of immu-
noregulatory cytokines, IL-10 and transforming growth factor
Activation of immuno-inflammatory pathways is a consistent (TGF)-β1 (Chao et al. 1991; Ogawa et al. 1998; Fletcher et al.
finding in ME/CFS (Moss et al. 1999; Cannon et al. 1997). 2010; Bennett et al. 1997; Nakamura et al. 2010). All in all,
Increased levels of PICs, such as IL-1β, TNFα and IL-6 have while a chronic, low-grade inflammatory response accompa-
been reported in people with ME/CFS (Maes et al. 2012a; nies ME/CFS, some patient groups feature elevations of Th1,
Broderick et al. 2010). The levels of IL-1 and TNFα show a Th2, Treg and maybe Th17 cytokines. Some ME/CFS patients
positive significant correlation with fatigue, autonomic symp- show a mixed response with activation of Th1 and Th2
toms and flu like symptoms (Maes et al. 2012b). Other markers cytokines. Th1 and Th2 subsets are indeed not mutually
of inflammation, e.g. lysozyme and polymorph nuclear neutro- exclusive, as Th17 and Treg subsets, but together facilitate
phil elastase, are also elevated (Maes et al. 2012b). The levels recovery from infection (Bot et al. 2004; Afzali et al. 2007).
of the latter correlate significantly and positively with levels of For example, IL-4 and Th2 immune responses monitor Th1
memory and cognitive impairment and phenomenological ex- responses and maintain homeostasis (Bot et al. 2004). It may
perience of infection. Increased levels of acute phase reactants, be that the different cytokine profiles in ME/CFS depend on
e.g. C-reactive protein and the α2 protein fraction obtained subgroups or staging of the disease, e.g. acute flares versus
during protein electrophoresis, further underscore the presence partial remission. In ‘Mechanistic explanations for the chronic
of an inflammatory response (Buchwald et al. 1997; Maes et al. and relapsing–remitting nature of ME/CFS’ we will discuss
2005a; Spence et al. 2008). Also the production of cyclo- how Th1 versus Th2 dominance and Treg functions may play
oxygenase 2 (COX-2) is significantly elevated in patients suf- a role in the relapsing–remitting nature of ME/CFS.
fering from ME/CFS (Maes et al. 2007b). The elevated levels A number of factors predispose to chronic inflammation.
of COX-2 are additionally related to key symptoms of ME/ IgG1 deficiencies often result in a decreased level of total IgG
CFS, such as a subjective experience of infection, hyperalgesia, (hypogammaglobulinemia). Along with IgG1, the IgG3 sub-
fatigue, and neurocognitive disorders (Maes et al. 2007b). class is most frequently present in the antibody response to
Neopterin, an indicant of cell-mediated immune activa- protein antigens. Decreased IgG3 levels are frequently associ-
tion is significantly increased in ME/CFS patients (Maes et ated with IgG1 deficiency (Herrod 1993). IgG1 and IgG3
al. 2012b). The same study showed that severity of fatigue, deficiency has been associated with a history of recurrent
autonomic and flu like symptoms also correlate positively infectious. IgG1 and IgG3 levels are reduced in ME/CFS (Bassi
with serum neopterin concentrations. Some but not all stud- et al. 2008; Hilgers and Frank 1994). Another feature which
ies found increased production of interferon (IFN)γ in ME/ predisposes to chronic inflammation is the decreased ratio of
CFS (review: Maes and Twisk 2010). Increased levels of IL- ω3/ω6 polyunsaturated fatty acids (PUFAs) in patients with
12 were detected by Fletcher et al. (2009), suggesting a ME/CFS (Maes et al. 2005b). Omega-3 fatty acids have anti-
Thelper (Th)1-like response in some patients. No significant inflammatory properties, whereas omega-6 fatty acids have
differences in the Th17 cytokines, IL-17 and IL-23, were pro-inflammatory effects (Simopoulos 2002). A genetic predis-
observed in patients with ME/CFS as compared with con- position is repeatedly observed in patients with ME/CFS. For
trols (Fletcher et al. 2009). Nevertheless, associations be- example, a significant increase in TNF–857 TT and CT geno-
tween fatigue scores and IL-17 levels were established in types, likely to be associated with increased production of
patients with primary Sjögren's syndrome (Haldorsen et al. TNFα and IFNγ; human leucocyte antigen class II allele
2011). This finding together with increased levels of PICs, HLA-DQA1*01; C/T polymorphism leading to His161Arg
including IL-1, IL-6 and TNFα, further suggest that a Th17 substitution in IL-17F; and IFN-γ +874T/A and IL-10 -592C/
response may occur in some patients with chronic fatigue. In A polymorphisms (review: Maes and Twisk 2010).
addition, the lowered expression of CD69 activation
markers on CD4+ T cells in ME/CFS (Mihaylova et al. O&NS pathways in ME/CFS
2007) may further skew towards Th17 responses. Indeed,
CD69 promotes some pathways that inhibit Th17 cell dif- ME/CFS is accompanied by increased reactive oxygen and
ferentiation (Martín and Sánchez-Madrid 2011). nitrogen species (ROS/RNS) and activated O&NS pathways
A state of immune activation is further evidenced by ele- (Jammes et al. 2005; Meeus et al. 2009; Maes et al. 2006b,
vated expression of surface markers CD38+, HLA-DR on 2009b). Frequently reported abnormalities include O&NS
 Metab Brain Dis

damage to proteins, lipids and DNA (Maes et al. 2009b; activation by viral products, lipopolysaccharide (LPS), a
Maes and Twisk 2010). Patients with ME/CFS additionally constituent of the outer membrane of gram negative bacte-
show increased IgM-mediated responses to different NO- ria, PICs and free radicals, NF-κβ is translocated from the
adducts, indicating chronically increased nitric oxide (NO) cytoplasma to the nucleus where it binds DNA promoter
production (Maes et al. 2006b), and increased production of sequences and induces transcriptional activation of PICs,
inducible NO synthase (iNOS) (Maes et al. 2007b). In- such as IL-1, IL-6, and TNFα, COX-2 and inducible iNOS
creased IgM-mediated responses directed to palmitic and (Brasier 2006). Upon activation, the inhibitory IκB proteins,
myristic acid and the NO-adducts show that O&NS have that hold NF-κB in an inactive state, are tagged from pro-
modified the structure of fatty acids and proteins (Maes et al. teosomal degradation following phosphorylation by IκB
2006b). Reduced levels of the antioxidants zinc, coenzyme kinases. In many inflammatory disorders, NF-κB in chron-
Q10, dehydroepiandrosterone sulfate and glutathione have ically upregulated. In ME/CFS, the increased production of
also been reported (Manuel-y-Keenoy et al. 2000, 2001; NF-κB is associated with fatigue and a subjective feeling of
Kennedy et al. 2003, 2005; Maes et al. 2005a, 2006a, infection (Maes et al. 2007a). Moreover, there were signif-
2009a; Maes 2011a). Low grade inflammation, activated icant and positive intercorrelations between the production
O&NS pathways and impaired oxidative defenses likely of NF-κB, COX-2, and inducible iNOS, suggesting that the
interact to increase the magnitude of abnormality in each increased production of COX-2 and iNOS is driven by the
leading to a vicious cycle (Maes and Twisk 2010). The transcription factor NF-κB. Thus, increased production of
symptoms of fatigue, malaise and pain, positively and sig- NF-κB is response to viral and bacterial infections may be
nificantly correlate with markers of lipid peroxidation and one key mechanism modulating the immuno-inflammatory
protein oxidation/nitrosylation (Kennedy et al. 2003, 2005; and O&NS pathways in ME/CFS.
Maes et al. 2006b; Maes and Twisk 2010; Maes 2011a). The 2-5A/RNaseL and PKR pathways are also upre-
Studies have demonstrated increased ventricular lactate in gulated in individuals with ME/CFS (Vojdani and Lapp
ME/CFS using 3 Tesla proton magnetic-resonance spectros- 1999). Importantly, the latter pathways have antiprolifer-
copy (Murrough et al. 2010; Mathew et al. 2009; Shungu et ative and antiviral effects and are induced by interferons
al. 2012). Ventricular CSF lactate was significantly in- in response to viral infections. Moreover, the enzyme
creased in ME/CFS as compared to normal volunteers that synthesizes 2-5A, i.e. 2′-5′-oligoadenylate synthe-
(Murrough et al. 2010). During exercise lactate is associated tase, is activated during bacterial infections. PKR is also
with the production of radical oxygen species and acidosis activated by bacterial LPS and PICs, including IL-1 and
(Groussard et al. 2000). Lactate is an antioxidant that scav- TNFα.
enges free radicals and attenuates lipid peroxidation, where-
as acidosis is a potent oxidative condition (Groussard et al. Bacterial translocation
2000).
The presence of O&NS is known to lead to mitochondrial The presence of intestinal permeability and resultant bacte-
damage in neurological diseases (Lin and Beal 2006; Trushina rial translocation into the lamina propina, the lymph nodes
and McMurray 2007) and is likely the source of mitochondrial and possibly the systemic circulation, is evidenced by the
dysfunction seen in people with ME/CFS (Maes and Twisk presence of IgM and IgA mediated immune responses
2010). Specific and highly sensitive alterations in the avail- against LPS of different gram negative bacteria in up to
ability of adenosine triphosphate (ATP), inadequate supplies 40–60 % of people with ME/CFS (Maes et al. 2012c). This
of ATP, and oxidative phosphorylation have been reported in may be due to the presence of systemic inflammation, which
neutrophil mitochondria of individuals with ME/CFS (Myhill can reduce the integrity of epithelial tight junctions. The IgA
et al. 2009; Vermeulen et al. 2010). Another study reported responses positively and significantly correlate with the
that all individuals with physio-somatic symptoms in depres- levels of PICs, such as IL-1β and TNFα, and neopterin
sion had a significantly lower ATP production in muscle (Maes et al. 2012c). LPS from translocated commensal
biopsies compared to controls (Gardner and Boles 2008). bacteria may provoke a peripheral immuno-inflammatory
response by binding to the Toll-like receptor-4 (TLR4)
Intracellular signaling networks complex, which in turn activates intracellular signaling
pathways, such as NF-κB, which subsequently will induce
A number of different signaling networks are upregulated in genes of PICs, iNOS and COX-2 (Maes et al. 2012c).
ME/CFS. Studies have demonstrated higher production of Increased LPS may also explain other immuno-
unstimulated, and TNFα- and PMA-stimulated NF-κB, inflammatory signs in ME/CFS, such as increased neopterin
cyclo-oxygenase-2 and inducible iNOS (Maes et al. 2007a, and elastase levels. Indeed, LPS may stimulate the produc-
b). NF-κβ is a major upstream molecule, which regulates tion of neopterin by monocytes/macrophages and elastase
immuno-inflammatory and O&NS responses. Upon by neutrophils and monocytes (Maes et al. 2012c).
Metab Brain Dis

Autoimmune responses variable surface antigen proteins, which continually change

their antigenicity (Simmons and Dybvig 2007; Le Grand et al.
Increased levels of B cells such as CD19+, CD 20+ and CD21 1996). Chlamydiae hijack signaling pathways that prevent the
+ have been reported (Tirelli et al. 1994). IgM mediated host cells from undergoing apoptosis and protect the infected
autoimmune responses towards self antigens whose structure cells from attack by host defenses (Zhong 2009). Each human
has been damaged by O&NS also occurs in ME/CFS (Maes et herpes virus studied has evolved cell biological solutions to
al. 2006b). These involve autoantibodies to anchorage mole- avoid or mitigate problems posed by the human immune
cules, palmitic and myristinic acid, which are essential for response (Gewurz et al. 2007). Herpes virus evasion of T-
normal cellular function (Maes et al. 2006b). Other autoanti- cell immunity includes latency, restriction of viral gene ex-
bodies towards Sa antigen, cell nucleus, and cardiolopin and pression to immuno-privileged sites (CNS), interference with
serotonin, gangliosides, vasoactive neuropeptides, and cholin- complement, cytokines, apoptosis and NK cell activity, and
ergic receptors have all been reported in large groups of ME/ expression of immuno-evasins, i.e. molecules that disrupt
CFS patients (review: Maes. 2011b; Nishikai et al. 2001; normal immune physiology. Coxsackie B3 employs a
Ortega-Hernandez and Shoenfeld 2009). In the next sections virally-encoded protein, i.e. 3Cpro, to degrade molecules,
we will further explain the mechanisms that may cause auto- which function downstream of pattern recognition receptor
immune responses in ME/CFS. signaling (Mukherjee et al. 2011; Wessels et al. 2006). Asper-
gillus species employ the following strategies: binding to
complement regulators, which avoids the host complement
Role of pathogens in ME/CFS attack (Behnsen et al. 2008; Radolf 1994); shielding of stim-
ulatory surface recognition molecules; induction of anti-
Viral and bacterial infections probably play an important inflammatory signals; complement evasion; and shedding of
role in ME/CFS, either as trigger or maintaining factors decoy components (Chai et al. 2009).
(Maes and Twisk 2010; Maes 2011a; Komaroff and Cho Environmental signals at the inflammatory site induce
2011; Broderick et al. 2010). The overall picture of activated monocytic mobilization and differentiate these cells into
immuno-inflammatory pathways in ME/CFS, e.g. increased macrophages or dendritic cells (Ingersoll et al. 2011). Cel-
NF-κB, 2-5A/RNaseL and PKR pathways, PICs and bacte- lular immune activation leads to the upregulation of PICs,
rial translocation, support the hypothesis that viral and bac- e.g. TNFα, IL-1β and IL-6, and initially Th1 cytokines, e.g.
terial infections play a major role in the onset of ME/CFS IL-12 and IFNγ (Halliwell and Gutteridge 1999). Chronic
(Maes and Twisk 2010). Not only the immunological and persistent infections can induce prolonged immune
anomalies but also the distinctive gene expression are in system activation, leading to high levels of localized or
accordance with viral or bacterial infections (Maes and systemic O&NS, which leads to oxidative damage to pro-
Twisk 2010; Broderick et al. 2010). ME/CFS often begins teins lipids and nucleic acids. Prolonged activation of the
with a severe flu-like infection (Naess et al. 2010) and immune system leads to damage to antioxidant defenses.
epidemics of ME/CFS have repeatedly been described in Figure 1 shows the effects of pathogens on the immune
the literature (Strickland et al. 2001). A number of patho- system leading to immuno-inflammatory cascades.
gens have been associated with ME/CFS such as Borrelia
burgdorferi, P. aeruginosa, Mycoplasma, Chlamydia, Cyto-
megalovirus, HHV-6, and EBV, Coxsackie and Aspergillus Transition to a chronic inflammatory state
(review: Maes and Twisk 2010).
A wide range of pathogens commonly found infecting Not only persistent infections can create a chronic inflammato-
people with ME/CFS are capable of establishing prolonged ry state, but also acute microbial infections can lead to chronic
infections as a result of developing sophisticated adaptations systemic inflammation, whether the infection becomes chronic
to avoid or mitigate the effects of the host immune response or is cleared by the immune system (Pincus 2005). Processes
(Hilgers and Frank 1994; Zhang et al. 2010; Stephensen et al. that may explain chronic systemic inflammation are, for exam-
2005). Borrelia burgdorferi, for example, persists in the host ple, damage by O&NS and autoimmune responses generated
and has strategies for immune evasion that include immuno- by infections or mounted against self-antigens that have been
genic surface-exposed proteins as potential virulence determi- modified by O&NS (Maes et al. 2006b). Thus, activation of
nants (Radolf 1994). Borrelia burgdorferi undergoes antigenic O&NS pathways may cause O&NS damage depending on the
variation, so that the configuration of the exposed proteins state of the antioxidant defenses, and lead to elevations of NF-
also changes in the host over time (Bankhead and Chaconas κB levels. O&NS damage to lipids and proteins can change
2007). P. aeruginosa evades human complement attack by their structure so that they are regarded as 'non self', leading to
binding human regulators to its surface (Kunert et al. 2007). the generation of auto-immune responses and autoreactive T
Mycoplasma can evade the host response by generating cells (Maes et al. 2006a, b).
 Metab Brain Dis

Fig. 1 Effects of pathogens on the immune system leading to immuno- inflammatory cytokines (PICs), e.g. tumor necrosis factor-α (TNFα),
inflammatory cascades. Different pathogens in ME/CFS may activate interleukin-1 (IL-1) and IL-6, are increased in individuals with ME/
the immuno-inflammatory pathways, reactive oxygen and nitrogen CFS. This disease can feature elevations of Thelper (Th)1, Th17, Th2
species (ROS/RNS), oxidative and nitrosative stress (O&NS) path- and Tregulatory (Treg) cytokines. Increased O&NS, through the for-
ways, and nuclear factor κB (NF-κB) through the Toll-like receptor mation of neoepitopes, and enhanced Th17 and Th1 responses increase
(TLR) complex, and consequently inducible nitric oxide synthase the risk to develop autoimmune reactions
(iNOS) and cyclo-oxygenase-2 (COX-2). Consequently, pro-

Different infections can initiate or exacerbate a chronic in- cells (Fujinami et al. 2006). The latter cells are subsequently
flammatory condition and cause autoimmune responses, using lysed by cytotoxic CD4+T cells (Hahn et al. 1995).
processes described as molecular mimicry, bystander damage It is also possible that the initial infection may create autor-
and epitope spreading (Fujinami et al. 2006). Autoreactive T eactive T cells, but insufficient inflammation to induce overt
cells can be formed when the pathogen contains epitopes, which pathology (Hahn et al. 1995). Nevertheless, autoreactive T cells
are cross reactive to host molecules, leading to autoimmune can be activated by subsequent infections with a broad range of
targeting of both pathogen and self epitopes. Epitope spreading pathogens leading to overt inflammatory damage (Hahn et al.
and bystander damage are other sources of chronic immune 1995). This fertile field, induced by the interaction with the
activation, inflammation and autoimmune responses. Bystander primary infecting agent, can change with time (Fujinami et al.
cell death, which is caused by pathogen specific T cells, may 2006). The initial priming infection and subsequent challenges
increase the release of self-epitopes that induce de novo T cell that produce symptoms may be separated by many years and
responses. Pathogen-specific T cells may initiate bystander acti- sometimes more than one challenge is needed to induce symp-
vation by migrating to areas of infection, where they encounter toms. A fertile field can also be generated when an infection
pathogen-infected cells that present pathogen peptides in the with a pathogen, which shows molecular mimicry to self CNS
context of MHC human leukocyte antigen class I molecules to molecules, primes autoreactive T cells without initiating auto-
T cells. The CD8+ T cells recognize these infected cells and will immune inflammatory disease. Later challenges may then trig-
release cytotoxic granules which may result in the killing of the ger these autoimmune cells to cause overt symptoms (Fujinami
infected cell. Consequently, the dying cells, the CD8+ T cells et al. 2006).
and macrophages within the inflammatory focus, release PICs
and ROS/RNS, which may cause bystander damage of unin-
fected but neighbouring cells (Fujinami et al. 2006). This may From peripheral inflammation to neuro-inflammation
result in additional immunopathology (Duke 1989; Smyth and
Sedgwick 1998), because self proteins may be released and It is well known that peripheral inflammation may induce a
engulfed by dendritic cells, macrophages and antigen presenting behavioral complex characterized by fever, anorexia, weight
Metab Brain Dis

loss, and behavior inhibition, including reduced locomotor peripheral immuno-inflammatory signals activate the produc-
activity and listlessness (Goehler et al. 2005). Circulating tion of PICs in the amygadala, which acts to coordinate
PICs and other inflammatory and O&NS molecules may behavioral, CNS and autonomic responses (Engler et al.
affect brain function through several routes, mainly humoral 2011). These bottom-up pathways may explain that systemic
and neural pathways (Ferrari and Tarelli 2011). The blood inflammation is accompanied by neuro-inflammation and be-
brain barrier (BBB) controls the passage of inflammatory havioral changes. For example, systemic LPS administration
compounds from the plasma to the brain. There are several may elicit neuro-inflammation with increased brain TNFα,
ways by which these substances can cross the BBB (Perry et which remains elevated for months and is associated with
al. 2010). Firstly, these substances can enter the brain through behavior symptoms, including fatigue, malaise, and hyper-
the areas that lack a BBB, e.g. the circumventricular organs alagesia (Qin et al. 2007). Moreover, once the immuno-
(Whitton 2007). Secondly, cytokines may cross the BBB inflammatory signals have arrived in the CNS via the vagal
using specific transporters (Kim and de Vellis 2005). Thirdly, afferents, a counter-regulatory anti-inflammatory reflex re-
BBB permeability may be increased as a consequence of sponse is mounted that tends to downregulate the peripheral
immuno-inflammatory stimuli. For example, Th17 T cells immuno-inflammatory response (Perry et al. 2007; Tracey
can infiltrate the brain through the BBB via loosening of the 2002). These counter-regulatory responses will be discussed
endothelial tight junctions by increased secretion of IL-17 and in ‘Mechanistic explanations for the chronic and relapsing–
IL-22 (Jadidi-Niaragh and Mirshafiey 2011). Fourthly, periph- remitting nature of ME/CFS’.
eral stimuli may activate endothelial cells which in turn may
induce immune signals in the CNS (Ransohoff and Perry
2009). For example, Parkinson’s Disease is accompanied by Neurological dysfunctions in ME/CFS
breakdown of the BBB which allows noxious blood-borne
substances to penetrate in the CNS (Kortekaas et al. 2005). Single-photon emission computed tomography (SPECT)
Likewise, disruption of the BBB allows the extravasation of scans may reveal significantly lower cortical/cerebellar re-
PICs and immune cells, which can activate microglia and, gional cerebral blood flow frequently in the frontal, parietal,
therefore, induce neuroprogression (Leonard and Maes 2012). temporal, occipital, brain stem and throughout the cerebral
Neuroprogression is a progressive process, which is induced cortex (Schwartz et al. 1994; Biswal et al. 2011; Patrick et
by inflammatory and O&NS processes, and that is character- al. 2008). Positron emission tomography (PET) scans may
ized by neurodegeneration, reduced neurogenesis and neuro- reveal decreased density of 5-HT transporter in the brain
nal plasticity, and/or neuronal apoptosis (Berk et al. 2011). (Yamamoto et al. 2004). Proton magnetic resonance spec-
The second route of immune-to-brain communication is troscopy has revealed various abnormalities in metabolic
the neural pathway, which transmits peripheral inflammatory pathways in the brain (Chaudhuri et al. 2003; Chaudhuri
signals to the CNS via the autonomic nervous system. The and Behan 2004). Barnden et al. (2011) detected that white
most important afferent pathway that signals peripheral in- matter volume decreased with fatigue duration and they
flammation to the CNS is the vagus nerve. These neural found signs of impaired cerebrovascular autoregulation.
pathways are stimulated by inflammatory signals that increase The findings suggest that fatigue onset is accompanied by
the levels of brain cytokines (Perry et al. 2003, 2010; Tracey an insult that suppresses cognitive activity and modulates
2002). The role of the vagus nerve is crucial in inducing the autonomic system (Barnden et al. 2011). Elevated numb-
neuro-inflammation and activation of microglia (Goehler et ers of punctuate lesions have been detected in ME/CFS
al. 1997, 2005; Herkenham et al. 1998; Ericsson et al. 1997; without psychiatric comorbidity in the frontal lobes as com-
Benarroch 2011; Blatteis and Sehic 1997; Ek et al. 1998; pared to controls (Lange et al. 1999). 3 Tesla magnetic-
Saper 1995; Gallaher et al. 2012; Riazi et al. 2008; Engler et resonance imaging (3 T MRI) scans have revealed signifi-
al. 2011). Not only PICs, but also prostaglandins and comple- cant neuroanatomical changes, including reduced white
ment factors may activate the vagal nerve pathways, via matter volume (Puri et al. 2011). A 1.5 T MRI, on the other
chemoreceptors situated on glomus cells in the vagal para- hand, showed no abnormalities suggesting brain atrophy or
ganglia (Goehler et al. 1997). The latter serve as a monitoring white matter lesions in patients with ME/CFS (Perrin et al.
system that detects immuno-inflammatory stimuli in the 2010). Greco et al. (1997) found no specific white matter
lymph and spleen. Vagal afferents terminate in the dorsal abnormalities in ME/CFS. On SPECT imaging, ME/CFS
vagal complex of the caudal medulla, the area postrema, the shares some similarities with AIDS Dementia Complex:
nucleus of the solitary tract and the dorsal motor nucleus of the acute changes in radionuclide uptake in the younger popu-
vagus (Saper 1995). Ascending immuno-inflammatory sig- lation may be caused by inflammatory processes at the
nals activate microglia in the nucleus of the solitary tract and cellular or micro-vascular level (Schwartz et al. 1994). The
the doral motor nucleus of the vagus (Gallaher et al. 2012) and findings in ME/CFS are consistent with the hypothesis that
the hippocampus (Riazi et al. 2008). Subsequently, these this disease results from a viral infection of neurons, glia or
 Metab Brain Dis

vasculature (Schwartz et al. 1994). Thus, viral infection can In ME/CFS there are significant correlations between typ-
provoke neurological dysfunction by interfering with intra- ical symptoms, such as fatigue, malaise, a subjective feeling of
cellular mechanisms or membrane transport systems or cere- infection, sleep disorders, autonomic symptoms and post exer-
bral hypoperfusion due to vasculitis. All in all, these brain tional malaise and activated O&NS (see above) and immuno-
studies could indicate metabolic dysfunctions, neuroinflam- inflammatory pathways, including increased neopterin and
mation or maybe neuroprogression in patients with ME/CFS. TNFα concentrations (Maes et al. 2012a). This indicates that
Given the different findings on activated immuno- these characteristic symptoms of ME/CFS are in part mediated
inflammatory pathways in ME/CFS, it comes as no surprise through effects of immuno-inflammatory and O&NS path-
therefore that autonomic (Newton et al. 2007; Winkler et al. ways. We have previously reviewed that PICs, e.g. IL-1 and
2004) and endocrine abnormalities (Van Den Eede et al. 2007; TNFα, and Th1-like cytokines, such as IFNγ, activated
Demitrack et al. 1991; Demitrack and Crofford 1998) accom- O&NS pathways and lowered antioxidant levels, including
pany ME/CFS. Recently we have reviewed the autonomic coenzyme Q10 and zinc, may elicit the characteristic symp-
dysfunctions and orthostatic abnormalities in ME/CFS (Maes toms of ME/CFS, such as fatigue, malaise, and neurocognitive
and Twisk 2009). Autonomic symptoms are associated with and autonomic symptoms (Maes and Twisk 2010; Maes et al.
cardiovascular abnormalities and may be explained by acti- 2012b; Anderson et al. 2012). For example, PICs are heavily
vated immuno-inflammatory, intracellular and O&NS path- implicated in the cause of fatigue in multiple sclerosis (MS)
ways, including increased TNFα, NO-related mechanisms (Heesen et al. 2006). Fatigue is also one of the most disabling
and NF-κB (Maes et al. 2011; Maes and Twisk 2009). symptoms in MS, with up to two thirds of patients describing
Hypothalamic-pituitary-adrenal (HPA) axis hypofunction has fatigue as their main complaint (Schwid et al. 2002). TNFα, as
been established in part of individuals with ME/CFS (Scott et a principal proinflammatory mediator, is associated with MS-
al. 1998). This entails decreased production of cortisol, related fatigue. This is in support of a pathogenic role of the
blunted diurnal variation of cortisol, and blunted responses MS-related inflammatory process in the development of fa-
to a variety of provocation tests, including psychological and tigue (Flachenecker et al. 2004). Also, the production of Th1
physical stressors (under review). Also these alterations in cytokines, e.g. IFNγ, in MS patients is associated with the
HPA-axis function may be explained by immuno- extent of fatigue (Pokryszko-Dragan et al. 2012). Other stud-
inflammatory and O&NS effects, including increased NO ies have reported that TNFα, IL-1β and IL-6 could be in-
production attenuating HPA-axis functions (under review). volved in the pathophysiology of mental fatigue through their
ability to attenuate the astroglial clearance of extracellular
glutamate (Rönnbäck and Elisabeth Hansson 2004). An ad-
Mechanistic explanations for the onset of ME/CFS verse effect caused by specific PICs, such as IL-1, on learning
symptoms including post exertional malaise and memory capacities, has been observed in several experi-
mental systems. IL-6 facilitates lipopolysaccharide-induced
This section will propose an immuno-inflammatory explana- disruption in working memory and expression of other PICs
tion for the hallmark symptoms of the disease, including (Sparkman et al. 2006). TFNα and IL-1β regulate sleep
fatigue, malaise, neurocognitive symptoms and a range of architecture together with IL-6 (Krueger and Majade 1987;
abnormal responses to exertion that may be delayed by 24 or Cavadini et al. 2007; Obal and Krueger 2003) and can lead to
even 48 h, which is often labeled as post exertional malaise sleep wake reversal and even complete loss of circadian
(VanNess et al. 2010; Van Oosterwijck et al. 2010; Carruthers control (Obal and Krueger 2003).
et al. 2011). The term refers to abnormal responses to even a As explained above, bacterial translocation through bind-
trivial increase in normal levels of physical or neurocognitive ing to the TLR4 complex induces NF-κB and immuno-
activity. Post activity relapse may therefore be a better term. inflammatory and O&NS pathways and thus may cause be-
This phenomenon is often reported by ME patients to be havioral and neuro-immune changes, including autoimmune
similar to the acute phase of influenza, with symptoms indi- responses directed against gangliosides (Maes et al. 2012c).
cating infection/inflammation, e.g. sore throat, lymph tender- Raised levels of IFNγ, IL-1, IL-2 and TNFα activate the
ness or swelling, malaise, hyperalgesia and brain fog (Twisk tryptophan-degrading enzyme, indoleamine 2,3-dioxygenase
and Maes 2009). Insignificant increases in physical activity or (IDO), which causes alterations in the tryptophan catabolite
minor cognitive tasks may exacerbate immune dysfunction, (TRYCAT) pathway (Anderson et al. 2012). Increased IDO
inflammation and O&NS thereby producing further signs of activation lowers plasma tryptophan and enhances the pro-
the disease (Twisk and Maes 2009). The effect may be duction of neurotoxic catabolites, e.g. quinolinic acid, a strong
delayed, but is predictable and accumulative, varying in dura- agonist of the glutamatergic N-methyl-D-aspartate (NMDA)
tion dependant on disease severity and accumulative activity receptor. Decreased tryptophan levels may cause physio-
levels (VanNess et al. 2010; Van Oosterwijck et al. 2010; somatic symptoms, such as fatigue, autonomic symptoms,
Carruthers et al. 2011). hyperalgesia and somatic presentations (Anderson et al.
Metab Brain Dis

2012). Disorders in the TRYCAT pathway are detected in during this “recharge” period, such as stress, will greatly
post-viral fatigue syndrome (Anderson et al. 2012). delay recharge and possibly create longer term disability by
In the presence of increased levels of IL-1 and TFNα, ATP further damaging the inner membrane. Chronically elevated
consumption is greatly accelerated, and levels of anaerobic cytokines act on the brain and hypothalamus to create a new
glycolysis and glucose consumption are increased (Berg et al. homeostatis of glucose metabolism, and the autonomic ner-
2003). The combined effects of these actions cause a greater vous system controlling heart rate, respiratory rate, blood
metabolic demand even in the resting state (Berg et al. 2003). pressure, vascular tone, gastric peristalsis, etc. (Del Rey et
TNFα increases ROS production in the mitochondrial elec- al. 2006). The autonomic symptoms observed in ME/CFS
tron transport chain. NO is known to inhibit mitochondrial could be obvious consequences of such a shift.
respiration, due to reversible binding to cytochrome C oxidase Increased TNFα and O&NS, iNOS, low ATP and high
thus competing with oxygen and inhibiting energy production TGFβ1 levels deplete glutathione (Castagna et al. 1995; Phelps
(Brown and Bal-Price 2003). Moreover, NO can be converted et al. 1995). A depletion in glutathione levels is often accom-
to other reactive species, including peroxynitrite, NO2, N2O3, panied by a partial blockade in the methylation cycle. More-
and S-nitrosothiols, that may inhibit mitochondrial respiration over, nitric and nitrous acid inhibit methionine synthase (Layser
and activate mitochondrial permeability transition, which 1978; Danishpajooh et al. 2001; Kerkeni et al. 2006; Culley et
eventually may trigger neuronal apoptosis or necrosis (Brown al. 2007). A number of studies mentioned earlier have demon-
and Bal-Price 2003). PICs can directly disrupt glucose ho- strated reduced glutathione in people with ME/CFS. A recent
meostasis and the availability of ATP. TNFα, IL-1β and IFNγ study confirmed these earlier findings and found that low
may significantly inhibit insulin secretion by beta cells in the glutathione levels and high lactate levels correlated with meas-
pancreas (Kiely et al. 2007). This increases cellular glucose urements of physical health and disability (Shungu et al. 2012).
consumption and lactate and glutamate levels (Kiely et al. Figure 2 summarizes how the different immuno-
2007). The resultant decrease in ATP may shift cellular me- inflammatory pathways may cause the typical symptoms of
tabolism towards a catabolic state, showing how mitochon- ME/CFS.
drial dysfunction can severely impair glucose metabolism.
PICs in general lead to the upregulation of nicotinamide
adenine dinucleotide phosphate (NADP) oxidase and resultant Mechanistic explanations for the chronic and relapsing–
increased production of ROS (Morgan et al. 2007). This remitting nature of ME/CFS
process may generate superoxide anion dependent damage
and formation of peroxinitrite which subsequently may con- ME/CFS is characterized by highly increased IgM-related
tribute to permanent damage to mitochondria (Mohankumar autoimmune response directed against disrupted lipid mem-
et al. 1991; Shintani et al. 1993; Linthorst et al. 1995). IL-1 not brane components, by-products of lipid peroxidation, an-
only causes hypoglycemia, but also resets glucose homeosta- chorage molecules, and NO-modified amino-acids as
sis in the brain; both phenomena together favor an increased compared with normal controls (Maes et al. 2006b). These
uptake of glucose by immune cells during inflammation (Del results show that self-epitopes, which are normally not
Rey et al. 2006). All in all, glucose usage can easily exceed detected by the immune system, have become immunogenic
supply and the increased demand for ATP cannot be met since following damage by O&NS (Maes et al. 2006b). A distinc-
mitochondrial functions are compromised by TNFα and NO. tive pattern of proteins modified by oxidative stress in
Cytokines can also lead to cerebral hypoperfusion via pro- people with ME/CFS was also reported in a recent study
longed exposure to IL-1β (Maher et al. 2003). The ensuing involving proteomic analysis (Schutzer et al. 2011).
lack of glucose would potentially explain the brain fog that so Such antibodies directed against lipids have also been
many people with this illness complain of. detected in remitting-relapsing MS (Geffard et al. 2002;
TNFα reduces mitochondrial respiration via effects at the Boullerne et al. 1996). However the latter study reported
level of complex III of the electron transport chain and by that there was no significant level of IgM against azelaic
ROS production (Samavati et al. 2008; Gudz et al. 1997). acid detected, whereas Maes et al. (2006b) found increased
The latter may induce opening of mitochondrial permeabil- IgM responses directed against azelaic acid in ME/CFS
ity transition pores, which may cause uncoupling of oxida- patients. The circulating IgM antibody titers in MS appear
tive phosphorylation (Chernyak 1997). The condition of to be related to the presence of inflammation, because they
increased ATP consumption and mitochondrial damage increase during relapses and decrease during remissions
means that exceeding a threshold of physical and mental (Bodet et al. 2004). This suggests that the level of immune
exertion will lead to all available ATP becoming exhausted activation, O&NS and magnitude of autoimmunity may in
and thus a crash may ensue. It takes damaged mitochondria fact be greater in ME/CFS than in MS.
time to replenish said ATP, leading to a profound post- Increased levels of peroxinitrite and nitrosothiols and low-
exertional disability. Anything that increases TNFα activity ered levels of reduced glutathione have been found in the CSF
 Metab Brain Dis

ME / CFS

COX-2 Hyperalgesia, neuro-

cognitive ss

Infections iNOS / O&NS Fatigue (muscle)

Viral and bacterial NF- B
NFNF
infections
Autoimmunity Disabling fatigue
Bacterial Epitope
translocation spreading
Disabling fatigue,
Bystander
NFNF PICs malaise, neuro-
damage cognitive and
autonomic ss,
Mimicry sleep disorders
Tryptophan
TRYCATs Physio-somatic ss

Mitochondria Physio-somatic ss
ATP Disabling fatigue
Glutathione PEM

Lactate Disabling fatigue, pain

P53 Exhaustion, PEM

Brain and
Neuro-immune Mental fatigue, neuro-
disorders cognitive ss

Fig. 2 Immuno-inflammatory pathways causing the typical symptoms and epitope spreading, and O&NS damage to self-epitopes. PICs and
of Myalgic Encephalomyelitis (ME) and chronic fatigue syndrome O&NS processes may activate the tryptophan catabolite (TRYCAT)
(CFS). Different pathogens activate nuclear factor κB (NF-κB) and pathway, cause mitochondrial dysfunctions including lowered ATP
consequently cyclooxygenase 2 (COX-2), inducible nitric oxide syn- levels and brain dysfunctions. Upon activation of NF-κB, tumor sup-
thase (iNOS), oxidative and nitrosative stress (O&NS) pathways and pressor p53 may be downregulated. Translational research has shown
pro-inflammatory cytokines (PICs). Autoimmune responses may ensue that these biological aberrations may cause the different symptoms (ss)
through different mechanisms, including bystander damage, mimicry of ME and CFS, including post-exertional malaise (PEM)

of patients with MS, suggesting a role for nitrosative stress in and a cascade of further inflammatory damage and dysfunc-
MS (Calabrese et al. 2003). This situation is also found in ME/ tion of mitochondria, constituting a flare up of active disease
CFS, as discussed earlier, and therefore following factors or relapse.
could contribute to relapses in MS and ME/CFS. Innate pat- We tentatively propose that (partial) remission is induced
tern recognition receptors recognize O&NS damaged self by the response of the CNS to immune activation. The CNS
epitopes, and the various components of the innate immune modulates immune responses through neuronal and hor-
system, including innate IgM antibodies, collaborate to medi- monal effects. Thus, the sympathetic and parasympathetic
ate their removal (Weismann and Binder 2012). In MS, IL-6 system and neuroendocrine axes attenuate immune
and TNFα levels are significantly increased during relapses as responses, whereas the peripheral nervous systems reinforce
compared to remission (Hautecoeur et al. 1997), as are IL-17 local immune responses (Sternberg 2006). In the first stage,
and IL-23 (Wang et al. 2011). Plasmacytoid dendritic cells, the peripheral immune and nervous systems work together
which are elevated in the CNS during relapses, may be to activate local immune responses and to eliminate invad-
explained by either virus infections or down regulatory pro- ing pathogens. In a later stage, however, counter-regulatory
cesses (Longhini et al. 2011). This dendritic subset is impor- neuronal and neuroendocrine mechanisms are mounted that
tant in stimulating or downregulating effector T cells in MS tend to terminate inflammation and thus restore host homeo-
(Geffard et al. 2002; Bayley-Bucktrout et al. 2008). By stim- stasis (Sternberg 2006). Activation of the vagus nerve indu-
ulating the maturation of dendritic cells, and upregulating the ces the release of transmitters that facilitate Th2 responses
membrane expression of CD80, CD86, CD83, and HLA-DR (Liang et al. 2011). Activation of the vagus nerve decreases
(Csillag et al. 2010), O&NS induces maturation of dendritic the expression of M1 monocytes, which produce TNFα, IL-
cells (Kantengwa et al. 2003). Moreover, NF-κB is activated 6, and IL-1β. Together, this indicates that activation of the
by threshold levels of oxidative stress (Khalaf et al. 2010) vagus neural circuit produces an anti-inflammatory cellular
leading to the activation of autoreactive T cells. Thus chronic milieu (Valdes-Ferrer et al. 2010).
inflammation, due to the causes mentioned earlier, leads to a The role of the peripheral nervous system in modulating
cycle where there is increasing damage to neoepitopes, ulti- the initial effects of immune activation and tissue inflam-
mately leading to a surge of PICs due to immune activation mation is complex and beyond the scope of this paper. The
Metab Brain Dis

antagonistic actions of the factors amplifying immuno- which may lead to a gradual worsening of symptoms. In-
inflammatory pathways and the CNS would potentially creasing levels of mitochondrial damage however act to
account for a relapsing-remitting pattern. The findings that “switch on” the transcription of p53. This can have the
the T cell pool of remitted MS patients is in a state of anergy effects of raising levels of Foxp3 and thus a reduction in
(Fransson et al. 2009) is of particular interest. Thus, active symptoms. P53 activation can also induce cell-cycle arrest
MS is associated with activated Th1/Th17 responses as and allow mitochondrial healing. A drop in free radical
discussed earlier, while it appears that people in remission production acts to suspend the activation of p53. This allows
have their immune system biased towards Th2 or Treg the levels of NF-κB and oxidative stress to downregulate
phenotypes. The immune abnormalities reported in people p53 and Foxp3, and remission is terminated. A number of
with ME/CFS vary between Th1 and maybe Th17, Th2 and such cycles are possible with a worsening of active disease
Th2/Treg responses. This is the pattern one would expect if over time. The presence of raised anticardiolipin antibodies
the relapsing-remitting nature of ME/CFS is produced by in up to 95 % of patients with ME/CFS (Klein and Berg
the interactions described above. A Th17 profile is induced 1995) is consistent with the presence of peroxidative mito-
by prolonged elevation of IL-6 and IL-23, which are in chondrial damage and loss of cytochrome C oxidase func-
themselves the product of elevated O&NS pathways and tion (Paradies et al. 1998).
chronic inflammation. IL-6 inhibits forkhead box P3 (scur-
fin, Foxp3) by activating the transcription of Signal Trans-
ducer and Activator of Transcription 3 (STAT-3) and hence Future research
attenuates the functions of Treg cells (Samanta et al. 2008;
Korn et al. 2009). Also, IL-23 inhibits Foxp3 and thus Future research should further examine the different inflam-
promotes Th17 differentiation (Zhu et al. 2010; Lal et al. matory and O&NS pathways, the transition to autoimmune
2011; Mus et al. 2010). responses and damage to mitochondria, the intracellular
Another plausible explanation for the chronic relapsing signaling networks involved, neuro-inflammation and brain
remitting nature of the disease revolves around tumor sup- metabolic changes in relation to the new diagnostic criteria
pressor p53. P53 is activated by factors that cause DNA (Maes et al. 2012a). We suggest that future research should
damage, including free radicals. P53 arrests the cell cycle, be based on cohort selection using PET scans to detect
activates DNA repair and initiates apoptosis. P53 is also activated microglia (Gerhard et al. 2006). We would suggest
crucial in matching increased mitochondrial function to objective testing for the existence of BBB permeability
increases in demand for ATP (Niu et al. 2005; Matoba et using dynamic Gadolinium-DTPA MRI scanning (Larsson
al. 2006). P53 regulates energy metabolism by balancing and Tofts 1992). The initial challenge would be to isolate
glycolysis and oxidative phosphorylation. In conditions of people with ME from those with CFS and CF (Maes et al.
oxidative stress, p53 activation results in decreased glycol- 2012a) via the use of PET, SPECT scans, 3 T MRI or
ysis. In such an environment, p53 expression acts to upre- Gadolinium-DTPA MRI.
gulate glutathione. The ultimate aim of both functions is the Mass spectroscopy and proteomic approaches for detect-
reduction of oxidative stress. p53 also regulates mitochon- ing and characterizing nitrosatively and oxidatively modi-
drial oxygen production via the synthesis of cytochrome C fied lipids, proteins and DNA produce specific sensitive and
oxidase. In normal circumstances activation of p53 leads to reproducible results (Aulak et al. 2001). Luminex assays for
an upregulation of mitochondrial respiration. NF-κB and the determination of cytokine levels in supernatants from
p53 have antagonistic strategies in the cell and therefore mitogen stimulated cultured peripheral blood mononuclear
cannot function simultaneously in the same cell (Ak and cells (PMBCs) are regarded as producing reliable and re-
Levine 2010). Thus, upon activation of one of these two producible results while minimizing intra and inter labora-
transcription factors the other is downregulated. Moreover, tory variation (Griffiths et al. 2002; Fulton et al. 1997; Fulya
STAT-3 activation leads to the downregulation of p53 ex- et al. 2006; de Jager et al. 2009). Real time reverse tran-
pression (Niu et al. 2005), while the latter is required for scriptase PCR provides a sensitive and quantitative measure
Foxp3 expression (Jung et al. 2010). of cytokine mRNA levels in PBMCs. STAT gene expres-
Therefore, it may be hypothesized that ME/CFS may be sion, p53 expression and Foxp3 transcription should be
accompanied by lowered p53 expression. Lower transcrip- measured.
tion of p53 causes a shift from ATP production by oxidative Mitochondrial dysfunction and ATP levels should be
phosphorylation to glycolysis. This can lead to a severe assessed using a combination of nuclear magnetic resonance
energy deficit and high levels of lactate production (Xiang spectroscopy, (31)P magnetic-resonance spectroscopy and
et al. 2010; Holley and St Clair 2009). Thus, increased blood tests measuring ATP synthesis in PMBCs (Dykens et
levels of NF-κB as observed in ME/CFS may cause a al. 2008; Chaumeil et al. 2009). Exercise stress testing has
gradual downregulation of p53 (Holley and St Clair 2009), the potential to do harm to people with ME/CFS and thus
 Metab Brain Dis

the non-ischemic repeat handgrip test should be considered and other inflammatory and O&NS compounds are detected
as a simple non-invasive test for mitochondrial dysfunction by the vagus nerve and other bottom-up signals leading to
(Meulemans et al. 2007). The aerobic forearm test provides the activation of microglia and neuro-inflammation. The
the basis of a simple measure of mitochondrial function and latter and O&NS pathways may persist once the initial
could be adapted to perform measurements over a 3 day infection has been cleared. Elevated and persistent O&NS
period (Garrabou et al. 2006). lead to damage to lipids, proteins and DNA which then
Genetic polymorphisms in the DNA repair mecha- become recognized by the immune system as non self. This
nisms and O&NS pathways, single nucleotide polymor- leads to the production of autoreactive T cells which cause
phisms (SNPs) in the NF-κB and p53 pathways may further damage. Descent into overt autoimmunity may be
further reveal genetic vulnerabilities to develop ME/ precipitated by further infections via molecular mimicry,
CFS. Next generation sequencing offers a rapid and bystander activation and epitope spreading. This ongoing
sensitive method for detecting the wide range of SNPs insidious process increases the concentration of PICs via a
in the human genome and offers promise for investigat- number of mechanisms and activates NF-κB, COX-2 and
ing SNPs in patients with ME and CFS now that sci- iNOS. These processes may also involve enhanced STAT-3
entific diagnostic criteria have been established (Maes et leading to the depletion of Foxp3 and chronic activation of
al. 2012a; Goya et al. 2010; Karchin 2009). the immune system. The combination of existing abnormal-
ities leads to mitochondrial damage and ATP deficit, auto-
nomic dysregulation, and neuroendocrine and brain
Conclusion changes, including lowered cerebral blood flow and white
matter volume, and maybe inflammatory lesions in the
Figure 3 shows the neuro-immune pathways that may lead brain. Increased PICs, O&NS and mitochondrial damage
to ME/CFS. A prolonged severe but non persistent infection and ATP deficit are responsible for the hallmark symptoms
by a number of potential pathogens may result in chronic of the disease including post exertional malaise. The antag-
activation of immune responses. The latter involve the acti- onism between peripheral immune activation, chronic in-
vation of immuno-inflammatory and O&NS pathways and flammation and CNS responses is held to be responsible for
depletion of the body’s antioxidant defenses. Elevated PICs the relapsing-remitting pattern of the disease.
Fig. 3 The neuro-immune
pathways that are involved in
the pathophysiology of ME/
CFS and may cause the typical
symptoms of ME and CFS (see
Conclusion, and Figs. 1 and 2
for explanation)
Metab Brain Dis

Acknowledgments The authors would like to thank Victoria Storey Boullerne A, Petry KG, Geffard M (1996) Circulating antibodies
and Jane Clout for secretarial services. There was no specific financial directed against conjugated fatty acids in sera of patients with
support for this study. The authors declare that they do not have a multiple sclerosis. J Neuroimmunol 65:75–81
conflict of interest. Brasier AR (2006) The NF-kappaB regulatory network. Cardiovasc
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