I came across a document* that shed more light on the pitfalls accompanying the search for a retrovirus in chronic fatigue syndrome in the 1990‚Äôs. The ups and the downs of the time with its more primitive technology were almost dizzying.
Let‚Äôs take a step back and examine how the whole process got started. Hillary Johnson covered this in depth in Osler‚Äôs Web but the new paper piqued my interest. It was no surprise that it was the ever-creative Dr. Cheney that threw the CFS ball into Dr. DeFreitas‚Äô court, but why did he choose her?
Made For CFS? Dr. DeFreitas wasn‚Äôt your ordinary virologist. She and her mentor Hilary Koprowski had been interested in the connection between central nervous system disorders and retroviruses for quite some time. After finding evidence of another retrovirus, HTLV-1, in multiple sclerosis patients, they produced a theory paper suggesting that smoldering retroviral infections play a role in several chronic neurological diseases. An apparently fairly prominent theory at the time it had caught, as we heard earlier, the eye of Tom Folks, the CDC retrovirologist.
The similar symptom presentations in AIDS and CFS (fatigue, sweats, sore throat, headache, muscle and joint pain, abdominal discomfort, the cognitive problems, dizziness, abnormal gait, sensory changes) and the reactivated herpesvirus infections in both diseases suggested a retroviral link was possible in chronic fatigue syndrome. After Dr. Cheney contacted her with a set of patients with both infectious onset and a suite of unusual neurological symptoms, the search was on.
(Easily the most prominent researcher associated with CFS, Hilary Koprowski invented the world‚Äôs first live polio vaccine, pioneered the use of monoclonal antibodies in cancer therapy, and has co-authored over 850 scientific papers. Accused by Edward Hooper, a journalist, in the book ‚ÄėThe River‚Äô, of inadvertently setting off the AIDS epidemic in his rush to create the polio vaccine, Dr. Koprowski sued and won a $1 judgment. At 94 he continues to publish on many different subjects. (A recent publication examined the effectiveness of inosine in multiple sclerosis). Several hundred papers later, he has never returned to chronic fatigue syndrome.)
The CFIDS Association started funding Dr. DeFreitas search for retrovirus in CFS in 1988. Two years later, after breaking the code on a blinded study of patients from Dr. Cheney and Dr. Bell, the DeFreitas test indicated that 83% of the CFS patients were positive for the gag sequence of HTLV-II as were thirty-eight percent of the exposed controls but none of the non-exposed controls. In September 1990, at a Kyoto conference, they disclosed their findings. With the publication of their May 1991 paper, interest in retroviruses in chronic fatigue syndrome zoomed. .
‚ÄėThe First Retrovirus‚ÄĚ Pt. I. – see Part I for more background
The Dr. DeFreitas Saga Comes to an End‚Äď Dr. DeFreitas‚Äô finding was clearly on rocky ground. With the exception of one instance at the CDC, a string of investigators had attempted and failed to reproduce her results; the CDC, the Gow-Behan team from Scotland, Dr. Herst at Oncore Labs, Chiron Labs and reportedly Dr. Levy and the Gallo team had all come up empty in their search for a retrovirus. She, in turn, had been unable to identify the CFS patients in a CDC study in March, 1992 ‚Äď at which point Osler‚Äôs Web reported that the CFIDS Association had stopped funding her. Dr. DeFreitas, however, would be funded by the CAA at least until the end of 1993 and she would have one last chance to prove her theory.
It was unclear, after all, whether any of the outside groups had exactly replicated her study. It was clear, in fact, that several of them had not, and with questions about the identity of the patients in the CDC study lingering the efficacy of her test was still up in the air.
Meanwhile, Dr. DeFreitas‚Äô participation in the blinded study funded by the CFIDS Association was set back by a hurricane in Miami and here‚Äôs where we leave her in Osler‚Äôs Web. It did not report that in May, 1993 Dr. DeFrietas made one last attempt, using her own methods and the ‚Äėright patients,‚Äô to show that her test was valid.
The Right Group ‚Äď The fact that this study contained the right patient cohort was important. Both Dr. DeFreitas and Dr. Cheney believed that the CDC may have inadvertently excluded the very types of patients that were positive for the virus. They had found that ‚Äėtypical‚Äô CFS patients (i.e., infectious, fluey, lymph gland enlarged, achy) patients did not test positive, but that the neurologically impaired, cognitively challenged, perhaps depressed patients did. Dr. DeFreitas‚Äô patients this time were from Dr. Bell‚Äôs Lyndonville pediatric cohort ‚Äď a group that she had identified correctly before.
The Same Result ‚Äď Like Dr. Herst and Dr. Martin, however, she was unable to correctly identify which patients had CFS and which did not. In fact, her results were strikingly similar to theirs, with her tests showing about half of the CFS patients and the controls testing positive for the virus. Interestingly, Dr. DeFreitas began to consider the idea that she had found an endogenous retrovirus, ie, one embedded in our DNA.
An Endogenous Retrovirus After All? The human genome contains thousands of endogenous retroviruses; broken up, degraded pieces of retroviruses that have managed to insert themselves into our genome. They are the bette noir of retrovirologists because while almost all of them are considered to be harmless they mimic many of the properties of infectious retroviruses. Dr. DeFreitas proposed that this endogenous escapee from our genome could interact with activated herpesviruses to produce chronic fatigue syndrome. Her general line of thought; that a two hit process involving herpesviruses produces CFS is still in play today.
Afflicted with a painful condition of reflex sympathetic dystrophy (RSD) but still believing in the merit of her work, and with what she believed was the virus sitting on ice in her jars, Dr. DeFreitas retired in the fall of 1994. In the end, she felt that she‚Äôd been asked to do too much, too early, and with too little.
With the publication of Osler‚Äôs Web the perception that the CFIDS Association had thrown Dr. DeFreitas ‚Äėto the wolves‚Äô settled in yet in hindsight their decision to stop funding Dr. DeFreitas was not difficult to understand. By the end of 1993 not only had numerous labs tried and failed to replicate her work but she had as well. The pattern was strikingly similar; except for Dr. DeFreitas initial foray, every report that an investigator had been able to distinguish patients from controls foundered once it was subjected to the rigors of a blinded test. With both an outside group (the CFS National Advisory Group) and their own Scientific Advisory Committee recommending against further funding the CAA appears to have brought their five years of funding Dr. DeFreitas to an end at the end of 1993.
Demonstrating what a difficult field retrovirology is, (particularly in this technologically ‚Äėprimitive‚Äô era), Dr. DeFreitas earlier finding of increased HTLV-I levels in multiple sclerosis would later be disproved as well. The last attempt to validate Dr. DeFreitas‚Äô finding of an HTLV-II-like retrovirus in ME/CFS came in 2002 when, citing new knowledge about the different strains of HTLV-II, two National CFIDS Foundation-funded researchers, Dr. Knox and Dr. Carrigan, failed to find any evidence of increased HTLV-II viral prevalence in ME/CFS patients relative to controls. http://www.ncf-net.org/forum/NCFDisclosureSpring04.htm
The Other Retroviral Players
The CDC has rightfully always borne the bulk of the interest in his period but several other players were involved. Besides the Gow/Behan group in Scotland and Chiron labs in the US, three other groups (Dr. Herst at Oncore Labs, Dr. Martin and Dr. Grossberg) were attempting to either replicate Dr. DeFreitas work or were working on their own retroviral findings.
Oncore Analytics Lab ‚Äď With the CDC having trouble replicating Dr. DeFreitas work, Dr. Herst‚Äôs report of finding high levels of positive tests in CFS patients using his version of Dr. DeFreitas‚Äô PCR test (called the CFIDS Associated Retroviral Assay (CARA)) created a great deal of excitement. He agreed to join (at his own expense) a blinded CFIDS Association study involving both Dr. Martin and Dr. DeFreitas.
In Phase One of the blinded study he attempted to differentiate between CFS patients and healthy controls from Dr. Levine‚Äôs practice. (Interestingly, Dr. Herst had identified all the CFS patients as positive during prior (unblinded) testing.) In the blinded test, however, only 52% showed positive. More disturbingly, his test indicated that 59% of the controls were positive as well. Dr. Herst modified his test and gave it another go but this time came up with no positive results. The CARA test was clearly not up to the task of differentiating CFS patients from healthy patients in a blinded study.
In Phase II of the study Dr. Herst examined blood from Dr. Bell‚Äôs, Dr. Cheney‚Äôs and Dr. Levine‚Äôs patients, but this time found that roughly equal numbers of patients and healthy controls tested positive. Given the questions whether different subsets of CFS patients had confounded the CDC‚Äôs results, it was important to note that Dr. Herst‚Äôs tests didn‚Äôt work on Dr. Bell‚Äôs pediatric patients, Dr. Cheney‚Äôs neurologically and cognitively challenged (but not fluey) patients or on Dr. Levine‚Äôs adult patients.
Dr. John Martin ‚Äď After Dr. DeFreitas‚Äô stunning announcement, Dr. Martin at the University of Southern California contacted the CFIDS Association for funding to assist his search for what he putatively identified as a Spumavirus. With Dr. Cheney enthusiastically endorsing Dr. Martin‚Äôs effort, the CFIDS Association expedited funding for him.
(In the next year the Association became a tax-exempt charity and formed a Scientific Advisory Committee (SAC) with infectious disease specialists and retrovirologists to regularly evaluate their funded investigators‚Äô efforts).
As with Dr. Herst, Dr. Martin report that with further refinements his testing procedures were finding higher and higher percentages of Dr. Cheney‚Äôs samples positive created a great deal of excitement. Stunningly, he reported that none of the controls were testing positive.
Dr. Martin then made what appears to have been a rather common error amongst CFS researchers at the time: he went public ‚Äď discussing his findings with Newsweek, New York Times and Wall Street Journal reporters ‚Äď prior to the publication of a paper. With his peers castigating him, Dr. Martin submitted two papers to peer-reviewed journals, only to have both rejected.
With Dr. DeFreitas having trouble at the CDC and at Oncore Labs and desiring clarity in an increasingly cloudy field, in early 1992 upon the advice of their Scientific Advisory Committee, the CFIDS Association funded a three-team blinded study involving Dr. Martin, Dr. Herst (as mentioned above) and Dr. DeFreitas using blood samples from three Dr. Bell, Dr. Cheney and Dr. Levine.
Upon breaking the codes in October 1992, Dr. Martin, like Dr. Herst, found that his ‚Äėspumavirus‚Äô appeared in roughly equal percentages of CFS patients and healthy controls.
Investigators Fight Back – Both Dr. Herst and Dr. Martin questioned the origin of the patients, the identities of the controls, how the samples were collected and delivered, and reported possible problems with their own labs. (We will see this type of response to negative results again and again: the reason the test didn‚Äôt work was because the wrong patients or wrong controls were included, or there were problems with sample collection and delivery, or problems in the lab, and the like. These are, in fact, all legitimate potential problems but they underscore how difficult it is to exactly replicate a study, and the difficulty funding organizations face in determining whether investigators‚Äô objections are legitimate or have become spurious.
CFIDS Association Asks for Help‚Äď at this point the CFIDS Association, deciding it wanted more input, requested assistance from the National CFS Advisory Council ‚Äď an important ad hoc group of CFS professionals of the time. The CFIDS Association expressed to the NFSAC an interest in more in-depth studies containing greater patient stratification, and the inclusion of immunological markers.
Dr. Martin Under Investigation ‚Äď The NFSAC recommended that a group of impartial virologists conduct an independent investigation of both Dr. Martin‚Äôs and Dr. DeFreitas‚Äô research, and that Dr. DeFreitas‚Äô funding should continue while Dr. Martin‚Äôs funding would be cut pending the outcome of the review. The more ambitious study would be put on hold until Dr. Martin‚Äôs review was completed.
Dr. Martin appeared to agree to the review, but then refused to provide the panel the manuscripts he had submitted for publication and never answered an in-depth series of questions about his work. Later in a rambling message he stated that his ‚Äúcritics [were]‚Ä¶no more qualified, no more committed than we to the scientifically challenging project. We are continuing to make good progress‚ÄĚ. Unwilling to participate in the outside review, Dr. Martin‚Äôs funding was cut off.
Aftermath – Dr. Martin did continue to work on what he now called a ‚Äėstealth virus‚Äô. The National CFIDS Foundation (NCF) reported that he had been stripped of his license in 2002 but followed up on his on his report in a 1992 patent that his ‚Äėvirus‚Äô was associated with a toxin very similar to the ciguatera toxin secreted by some tropical fish. Interestingly, the symptoms of ciguatoxin poisoning are very similar to those found in chronic fatigue syndrome. Further research funded by the NCF under the direction of Dr. Hokama, indicated the toxin Dr. Hokama found was a kind of unusual lipid or fat that appeared to be tied to inflammatory processes in ME/CFS as well as a wide variety of other diseases.
The ciguatoxin was not the biomarker the NCF had hoped for but the very high levels of the epitope in ME/CFS patients underscored the possible contribution inflammation plays in this disorder and federally funded research into the ciguatoxin epitope question continues today.
(How ironic it would be if two medical factors of potentially far-reaching import, XMRV and the ciguatoxin epitope, came to prominence after being reported in chronic fatigue syndrome ‚Äď currently the most poorly funded disease at the NIH.)
Dr. Sidney Grossberg – An accomplished researcher who had done a stint at the renowned Pasteur Institute in France under the discoverer of the HIV virus, Dr. Luc Montagnier, Dr. Grossberg jumped into the fray in the first quarter of 1992 with a report he‚Äôd isolated a novel retrovirus from the blood of a CFS patient. Happy to have such a renowned figure involved the CFIDS Association expedited funding for him. Dr. Grossberg went onto to get two grants from the NAIAD, becoming apparently the only researcher to receive federal funding from the NIH to specifically look for a retrovirus in the disease. Interestingly, Dr. Grossberg, too, was unclear whether he‚Äôd found an endogenous or exogenous retrovirus and like Dr. DeFreitas his virus appeared not to fit in any viral family.
Three years later in 1995 Dr. Grossberg still not published a paper on his virus. In 1997 Dr. Grossberg published a paper on a novel “JHK” virus produced by a cell line in conjunction with EBV. The CFIDS Association would still be supporting him in 1998 and then again in 2001 but as of 2010, Dr. Grossberg has never published any papers on retroviruses in chronic fatigue syndrome.
The Elusive Retroviruses ‚Äď CFIDS Chronicle Summer 1993