Dr. Shoemaker: Deficits In Cognitive Functioning

[Guest guest]

Dr Ritchie Shoemaker made a brilliant presentation at the 2009 IACFS/ME

conference in Reno, which basically lays out the fundamentals. No more

guesswork.

When C4A complement Activation factor shoots through the roof after a known

exposure to mold toxins, unrestrained cytokine response is now a measurable

immune abnormality.

Now it remains for " CFS researchers " to take an interest in those of us who have

always been interested in " The Mold Connection to Illness " .

Background: Our understanding of the pathophysiology of human illness acquired

following exposure to the interior environment of water-damaged buildings

(WDB-illness) has been transformed over time by advancements in unveiling the

role of innate immune mechanisms contributing to human illness (1, 2, 3, 4).

Initial emphasis on mycotoxins alone as causative agents of WDB-illness has

given way to recognition that multiple members of the indoor microbial world

make toxins and other antigenic compounds that initiate inflammation and cause

illness (5, 6). Recognition of the " chemical stew " that exists as a unique

ecosystem inside WDB, with multiple elements capable of initiating multiple

interacting cascades of host responses through differential gene activation and

activation of innate immune responses following pattern recognition of microbial

antigens now dominates current literature on WDB-illness.

Fundamental to the ultimate target of the research effort to define WDB-illness

is a need to explain (i) the genetic basis of differential susceptibility to

initial illness (ii) absence of recovery following removal from exposure and

(iii) accentuated inflammatory responses ( " sicker, quicker " ) seen in those

previously ill but then re-exposed to WDB. Results of research in WDB-illness

now implicate physiologic mechanisms including capillary hypoperfusion and

chronic inflammatory response syndromes (CIRS) demonstrated in affected patients

but not in controls (7). Understanding the basis of capillary hypoperfusion and

CIRS has already led to better understanding, treatment and prevention (primary

and secondary) of WDB-illness (8).

Previously presented data on WDB-illness supported the role of capillary

hypoperfusion induced by innate immune responses as a basic physiologic

mechanism in the illness (8). Application of the recognition of capillary

hypoperfusion could provide data to support use of diagnostic markers for

impaired executive cognitive function using magnetic resonance spectroscopy

measurements of lactate, and the ratio of glutamate to glutamine (G/G) in the

selected areas of the brain. Prior work from this site (8, 9) marked CIRS by the

near-universal deficiency of regulatory neuropeptides melanocyte stimulating

hormone (MSH) and vasoactive intestinal polypeptide (VIP), as well as reduction

of ADH response to hyperosmolality and reduction of VEGF which in turn is

correlated with low VO2 max seen on pulmonary stress testing. Elevated levels of

C4a; MMP9 and autoimmune markers of antigliadin and anticardiolipins in CIRS

have been identified. Clotting abnormalities are not uncommon in CIRS. This

occurrence may correlate with commonly observed clinical problems of hemoptysis

and epistaxis in cases.

TGF beta-1 has provided a new window of opportunity to study abnormal

T-regulatory cell function and autoimmunity in this illness as well as the

unexplained occurrence of unusual rheumatologic syndromes often seen in

WDB-illness (9). The newer understanding of innate immune responses is bringing

salutary new therapies to patients previously disabled by WDB-illness. Here we

present a database on 1000 consecutive patients (850 WDB-illness cases; 150

controls) seen since 2007 at one site.

Methods: Our first major hypothesis was (1) the same differences documented

previously between symptoms, VCS, HLA, MSH, ADH/osmolality, ACTH/cortisol, MMP9

between cases and in controls would be replicated; our second major hypothesis

was (2) elements of activated innate immune response known to reduce capillary

perfusion, i.e. low VEGF, high C4a and high TGF beta-1 would be enhanced in

cases compared to controls. Our minor hypothesis predicts (2a) differences

between cases and controls would be highly associated with HLA DR haplotype. If

(2b) TGF beta-1 were elevated, we would see evidence of abnormal T regulatory

cell function as manifested by increased presence of autoimmunity. Finally,

minor hypothesis (2c), if C4a were elevated, we would see the same elevation of

lactate in frontal lobes and hippocampus and reduction of G/G ratios as seen on

MR spectroscopy previously that in turn would correlate with symptoms of

executive cognition impairment recorded on a severity scale of 0 to 4, with zero

being absent and 4 being severe.

1000 consecutive adult patients seen at a single medical clinic site signed IRB-

approved HIPAA waivers (Copernicus IRB, Cary, NC) that permit use of baseline

data in research studies. Patients were labeled as being a case if they met a

restrictive, two-tiered case definition for WDB-illness published previously

(2). Controls were identified as patients coming to the site for well adult

physical exam without known untreated acute or chronic illness. Data was

extracted from charts retrospectively including symptoms (individual, from a

roster of 37; and total); visual contrast sensitivity testing (VCS); lab

studies: HLA DR by PCR, MSH, VIP, leptin, ADH/osmolality, ACTH/cortisol, MMP9,

PAI-1, CBC, CMP, CRP, ESR, lipid profile, testosterone, DHEAS, androstenedione,

GGTP, VEGF, erythropoietin, ACLA (IgA, IgM, IgG), AGA (IgG, IgA), TGF beta-1,

C3a, C4a, IgE, TSH, von Willebrand's (vWF) profile; and deep aerobic nasal

culture were also compared for cases compared to controls. MR spectroscopy data

on N-acetyl aspartate, choline, creatinine, myoinositol, lactate and ratio of

glutamate and glutamine (G/G) measured in left and right frontal lobes and

hippocampus were also analyzed. Individual measurements and test results were

compared using two-sample T-test.

Patients were excluded from the data set if they had untreated, active alcohol

abuse with abnormal liver functions, ongoing cocaine use, uncontrolled diabetes,

anemia, active hepatitis, occupational exposure to hydrocarbons, petrochemicals,

metal fumes and metal dusts as well as undiagnosed neurologic conditions.

Individuals requiring acute intervention for illness other than that acquired

from WDB were excluded.

Results: There was no difference between groups in gender, age or ethnicity.

Mean total symptoms were 21.4 in cases and 2.6 in controls. 37 individual

symptoms were assessed in all patients (N= 1000); results for all symptoms were

all different in cases compared to controls except for sinus congestion (p=.137)

and tremor (p=0.0064). VCS was different in cases from controls in all

frequencies tested, as shown by multivariate analysis; visual acuity was no

different. Six HLA DR haplotypes were present in cases compared to controls with

relative risk > 2.0 for 4-3-53; 7-2-53; 11-3-52B; 13-6-52A; 14-5-52B; and

17-2-52A. Labs with no differences (p > 0.001; N=1000) between cases and

controls were leptin, PAI-1, CBC, CMP, CRP, ESR, lipid profile, testosterone,

DHEAS, androstenedione, GGTP, erythropoietin, C3a, IgE, TSH. Labs with

differences (p <0.001; N=1000) were MSH, VIP, ADH/osmolality, ACTH/cortisol,

MMP9, VEGF, ACLA, AGA, TGF beta-1, C4a, vWF and presence of multiply antibiotic

resistant, biofilm-forming coagulase negative staphylococci (MARCoNS) in deep

aerobic nasal spaces. von Willebrand's profiles were abnormal in 67% of patients

compared to < 5 % of controls (p <0.001). There were statistically significant

differences (p < 0.001) between cases (N=759) and controls (N=86) for lactate

and G/G ratio, averaging a total of 5.2 abnormalities in eight measurements

(added four each for lactate and G/G) in cases and 0.9 in controls. A weighted

symptoms score (out of 24 possible) for six symptoms of executive cognitive

function showed an average of 23, 20, 16 and 13 for the highest to lowest C4a

quartile. NB: results table not presented.

Discussion: Our major and minor hypotheses were confirmed.

(1) Total and 35/37 individual symptoms, and VCS are again shown to be markedly

different in cases compared to controls, with results essentially identical to

prior published findings (1, 2, 3, 8, 9).

(2) Markers of capillary hypoperfusion (C4a, TGF beta-1 and VEGF) from innate

immune activation are present in cases but not in controls.

(2a) Finding relative risk > 2.0 for haplotypes of patients, found in a total of

24% of well patients, replicates earlier published relative risks.

(2b) TGF beta-1 elevation was associated with autoimmunity

(2c) C4a elevation was associated with impairment of executive cognitive

function.

The result of untoward innate immune activation is systemic capillary

hypoperfusion that can be measured directly in brain using CNS lactate and

indirectly in lung using VO2 max and anaerobic threshold. It remains likely that

the underlying reason for ongoing dysregulated innate immune response is

deficiency of regulatory neuropeptides MSH and VIP, a finding seen in > 90% of

cases (10). In control patients who invariably had normal MSH and normal VIP,

increased TGF beta, high C4a or low VEGF is rarely seen. Deficiency of both MSH

and VIP was not seen in controls but was common in cases. Given the

not-infrequent history of epistaxis and hemoptysis in this cohort of WDB-illness

patients the abnormal vWF findings are consistent with a similar acquired

coagulopathy commonly seen in systemic inflammatory illness due to endotoxemia

(12).

Persistent elevation of C4a, an otherwise short-lived anaphylatoxin, suggests

ongoing activation of mannose binding lectin pathway of complement activation,

thought to be due to ongoing autoactivation of the enzyme MASP2 (14), continuing

despite absence of an environmental source of antigenic stimulus of the MBL

pathway.

Studies of WDB-illness patients have noted neurologic symptoms (5), but other

than hyperacute trials of re-exposure, in which rising C4a correlates with

increasing cognitive dysfunction (7, 8), no studies have been published that

document a mechanism of illness acquisition. Finding the clear link between

peripheral inflammation (i.e. rising C4a) and central metabolic disturbances

(elevated lactate) provides a plausible mechanism of hypoperfusion to explain

cognitive impairment. Unpublished studies presented previously confirm that

reduction of C4a alone, using low dose erythropoietin injections, simultaneously

resolves the CNS hypoperfusion and cognitive symptoms (13).

Conclusions: These results are consistent with the hypothesis that WDB-illness

is a CIRS with ongoing capillary hypoperfusion. Symptoms taken as a whole create

a distinct cluster that classifies cases accurately without providing

mechanisms. Lab results show a dense, unregulated innate immune inflammatory

response without yielding symptoms. Linking labs and symptoms, especially when

linked together with VCS, a neurotoxicologic measure; provides a landscape

approach to a definable illness seen repeatedly in WDB-illness patients.

Treatment of this complex syndrome will involve sequential (1) removal from

exposure; (2) correction of toxin carriage, using VCS monitoring to assess

endpoints; (3) eradication of biofilm-forming MARCoNS; (4) correction of

elevated MMP9; (5) correction of ADH/osmolality; (6) correction of low VEGF; (7)

correction of elevated C4a (8) reduction of elevated TGF beta-1 and (9)

replacement of low VIP. Each of these steps using FDA-approved medications is

available to practicing physicians.

References:

1. Shoemaker R, House D. A time-series of sick building syndrome; chronic,

biotoxin-associated illness from exposure to water-damaged buildings.

Neurotoxicology and Teratology 2005; 27(1) 29-46.

2. Shoemaker R, Rash J, Simon E. Sick building syndrome in water-damaged

buildings: Generalization of the chronic biotoxin-associated illness paradigm to

indoor toxigenic fungi; 5/2005; Pg 66-77 in Johanning E. Editor, Bioaerosols,

Fungi. Bacteria, Mycotoxins and Human Health.

3. Shoemaker R, House D. SBS and exposure to water damaged buildings: time

series study, clinical trial and mechanisms. NTT 2006; 28: 573-588.

4. Janeway, C. Approaching the Asymptote? Evolution and revolution in

immunology. Cold Spring Harbor Symposia on Quantitative Biology. 1989; Vol LIV:

1-13.

5. Government Accountability Office 08-980; 10/08 Better coordination of

Research on Health Effects and More Consistent Guidance Would Improve Federal

Efforts

6. Rao C, Riggs M, Chew G, Muilenburg M, Thorne P, Van Sickle D, Dunn K, Brown

C. Characterization of airborne molds, endotoxins, and glucans in homes in New

Orleans after Hurricanes Katrina and Rita. Applied and Environmental

Microbiology 2007; 73(5): 1630-1634

7. AIHA continuing education program Round Table, Minneapolis 6/2/08; R

Shoemaker, S Vesper, G Boothe, G Cormier, K Lin co-panelists. Integrating Field,

Laboratory and Clinical data for the IAQ investigation. Comparison of indices of

human health and building healthy: SAIIE meets ERMI.

8 Shoemaker R. Sequential upregulation of innate immune responses during acute

acquisition of illness in patients exposed prospectively to water-damaged

buildings. ASTMH 11/07, Philadelphia, Pa

9. Shoemaker R. ASTM International, Section D22, Boulder Colorado 7/27/06.

" Defining causality of a biotoxin-associated illness by exposure to

water-damaged buildings: a case control series. "

10. Vignali D, Collison L, Workman C. How regulatory T cells work. Nature

Reviews Immunology 2008; 8: 523-532.

11. Brozska T, Luger T, Maaser C, Abels C, Bohm M. Melanocyte stimulating

hormone and related tripeptides; biochemistry, antiinflammatory and protective

effects in vitro and in vivo, and future perspectives for the treatment of

immune–mediated inflammatory disease

12. Rittirsch D, Flieri M, Ward P. Harmful molecular mechanisms in sepsis.

Nature Reviews Immunology 2008; 8: 776-787.

13. Shoemaker R. Correction of central nervous system metabolic abnormalities,

deficits in executive cognitive functioning and elevated C4a: a clinical trial

using low dose erythropoietin in patients sickened by exposure to water-damaged

buildings. 1/14/07 IACFS, Fort Lauderdale, Florida.

14. Wallis R, Dodds A, D, Sim R, Reid K, Schwaeble W. Molecular

interactions between MASP-2, C4, and C2 and their activation fragments leading

to complement activation via the lectin pathway. J Biol Chem 2007; 282: 7844-51.