Verbatim transcript of Prof. Bhupesh Prusty’s presentation to the Fatigatio E.V Research Seminar – 14th Sept. 2024

Weblink to the video recording on Youtube:

        ME/CFS-Fachtagung des Fatigatio e.V. am 14.09.2024 (Live-Stream)

1:41:01        Guten Morgen.  I Travel from Riga, but I live in Wurzburg, so it’s only a one hour journey for me. Not so much. It’s an honour for me to be here, to meet old friends. A lot of old friends, but also to meet some new faces.

1:41:23        Today, I’m not to give you results, bang, bang bang. But rather to share all the experiences that we have gained over the last 10 years. I’m in the field of ME/cfs research for almost 10 years.

1:41:40        I have a Lab which is fully dedicated to ME/cfs research.

1:41:47        Over the last 10 years, I have learnt many things and I’m going to share most of those ideas of mine. How mitochondria can play an important role in ME/cfs and also probably in Long-Covid and also, why do we think so.

1:42:12        So, if you know ME/cfs, definitely, (because many of you are patients), you know that mitochondrial dysfunction is one of the most common features that is discussed in this field.

1:42:17        So, what do we know from all of the literature that has happened…. all of the work that has happened in the past? The first thing that we know is that there are alterations in mitochondrial dynamics.

1:42:41        This is not only from our own work. It has been shown by many others and there is a belief in the field that there is something in the blood or in the serum that keeps the mitochondria in a dysfunctional state and you can actually transfer that from blood or serum to any healthy cell.

1:43:09        Ron Davis has shown this. Oystein Fluge has shown this and we have also shown this.

1:43:15        There are many papers which show that there is no change in mitochondrial mass or genenome copy number in patients.

1:43:24        I tend to agree with this. Many papers show there is lower mitochondrial membrane potential, deficiency in mitochondrial ATP generation.  There is less amount of glycolysis rate in these patients.

1:43:40        Some papers show increased oxidative stress in patients and decreased mitochondrial respiration. As we’ve heard from Rob, there is a change in mitochondrial protein or mitochondrial skeletal muscles in Long-Covid patients which are similar with ME/cfs patients.

1:43:59        But the majority of the work that is done in the field relating to mitochondria is mitochondrial metabolism.  And from some of the big papers in the field, we know that there is a lot of change in the metabolic Profile.  The metabolism that comes from mitochondria in the sera or plasma of ME/cfs patients.

1:44:23        There are three cardinal features of ME/cfs:

        PEM – as we heard.

        POTs – although not in all patients, but in some patients.

        And the third part is actually Fatigue.

1:44:35        Not all these three features are present in all of the patients, but many patients share.

        So far, we are not in a position to thread them all in one thread …. Finding one reason which would combine all of them.

1:44:54        Now, energy production.  So this is the mitochondrial ….. the energy production pathway.  We believe that we produce less amount of energy in these patients. But why?

1:45:09        This is something we have not understood so far.  But if you go a little bit into the literature,         one thing that can bind all of them together, is not about how much energy you produce, but rather whether you are able to use this energy properly or not.

1:45:28        Whether you have a balance of how much energy you produce and how much energy you spend.

1:45:34        And how is the mitochondrial health? Probably, in my opinion, one of the crucial missing things so far, is whether your mitochondria is in a good state. That it can produce the energy and it can recycle the mitochondrial proteins that can produce the energy. So, the turnover efficiency.

1:45:59        As Rob mentioned, people believe that exercise is good.

1:46:06        But if you ask ME/cfs patients, exercise is not good at all. And this argument has divided the people, that, why exercise is not good, when it is for every generally healthy Person? A paper came out in 2021 in “Cell metabolism”, one of the highest standard papers I would say. This paper is very interesting.

1:46:31        This paper says that even in a healthy Person, when the person goes from the baseline exercise to light training, moderate training and excessive Training, what happens is that the healthy mitochondria  …… (This Person has healthy Mitochondria) ….. but this healthy mitochondria, when it’s stressed too much, becomes bad.  It cannot produce enough amount of energy.

1:46:53        The person is not sick at all. The mitochondria is fine, but the mitochondria is not able to regenerate itself.  Mitochondria needs a chain of proteins. 68 proteins precisely, that helps it to produce the energy.  From this, 13 proteins are mitochondrially produced ….. it’s produced inside the mitochondria.  

1:47:13        These proteins all have to be recycled. You cannot have the same proteins all the time in your mitochondria producing energy. They have to break apart and new proteins have to come in to replace it.

1:47:28        This process is defective and plays an important role.  If you cannot regenerate these proteins, even a healthy mitochondria becomes sick.

1:47:39        A preview to this paper, Too much of a good thing in our body.  I think that this is one key feature which we are able to focus on.

1:47:50        How Viruses prevent the recycling of mitochondrial proteins that causes the defect in energy production or health of the mitochondria.

1:48:05        Now, we’re here to listen about mitochondrial dysfunction, right?  But the million dollar question here is, where is the mitochondrial dysfunction?

1:48:14        Is it in your brain?  Is it in your blood? Is it in your skeletal muscles? Is it in your heart or all throughout the body?  I don’t think so.

1:48:24        ME/cfs is a multi-system disorder.  Patients have unique properties.

1:48:29        They share some clinical features, but not all of the clinical features are exactly the same in every patient.

1:48:37        If mitochondria is the key to understand the disease, then why don’t all of the patients show all of the same clinical features?

1:48:50        Because if all of their mitochondria are defective, everywhere, they should all have the same features.  Alo, we can ask the question, if we target mitochondria, …..  we develop drugs to target mitochondria, can we resolve ME/cfs?  

1:48:57        Personally, I would say no, but yes, only to some extent, if we know where to target mitochondria.

1:49:05        Let’s just go through a little bit about the disease.  As I said, the core symptoms of the disease is the life-altering fatigue, which can last more than 6 Months.

1:49:15        Not all of the patients have that amount of fatigue, but the fatigue can be mental fatigue or physical fatigue.

1:49:30        It doesn’t have to be fatigue in the muscles.

        P.E.M (post-exertional malaise). Some patients have Orthostatic Intolerance.

        And having this Unrefreshing Sleep.

        These are some of the core symptoms, but patients do have other symptoms, which are highly variable. Some of them have Allergies, Mast Cell Activation, Sleep Disorders, Depression, Food Intolerance and Muscle Weakness.

1:49:57        So, from my experience from the last 10 years, working with infectious diseases, I would like to divide the disease into two parts:

1:50:05        The acute stage of the disease and the chronic stage of the disease.

1:50:11        The acute stage of the disease is the disease when it starts. The first few weeks, two months, or a maximum of up to one year

1:50:21        The bad part is that, that is the part when you don’t go to the doctor.

1:50:24        Because you can still survive. You don’t know that you have the disease….. most of the cases. Then comes the chronic part, which appears after a couple of months or years, which is when you see so many different conditions and then you reach to the doctor to find a solution.

1:50:45        Sometimes they’re interlinked, you have both the acute and the chronic disease going on, but sometimes it is no more …… the acute disease is no more there, you are in a chronic state of the disease.

1:50:53        I believe that mitochondrial dysfunction is involved in both states. But it is not exactly the same. We have to understand the mechanism of the acute disease ……. what Mitochondria does in the acute disease and what mitochondria does in the chronic disease, so that we can treat it, or so that we can target treatment accordingly.

1:51:10        Now, let’s go to the acute stage of the M.E.  

1:51:19        I believe that this is infection (in) origin.  One great example is the Long-Covid patients, having the disease after SARS-CoV-2 infection.

1:51:26        But potentially, there are many causes of this disease.

1:51:32        It can be SARS-CoV-2 directly. This is a hypothesis of survival of virus, viral proteins and things like that. But as Rob mentioned that it is not always the case.  

1:51:42        In my opinion, herpes viruses are one of the most prominent candidates, and of the nine herpes viruses, EBV is the most prominent one.

1:51:55        But still, there is a lot of evidence for the role of HHV6, HHV7, Type 1 Herpes Virus and Varicella Zoster also.  

1:52:04        There are other known triggers.  If you ask patients, some of them will say, wait, I didn’t have any infection when I became sick. I had an accident. There are examples.        

1:52:18        There are other triggers like trauma, stress, serial clinical conditions from other diseases or cancer treatment and things like that.

1:52:28        But remember that these stress, trauma, also reactivate herpes viruses. So, there can be a background role of virus infection in this.  

        So, each Virus has a different story.  

1:52:40        EBV is not comparable to SARS CoV-2. They all have a different mechanism.

1:52:45        So, (the) acute state of the disease can start from a different mechanism and that can be a different tissue origin.

1:52:51        So, the virus can be in a completely different tissue. The result is that you probably won’t find a marker for the acute stage of the disease, which you can link to M.E/cfs.

1:53:04        The consequence is that a different starting point for acute disease. We can take an example that maybe all of the neurological issues we see in patients, like brain fog, or other type of issues, can be explained as a consequence of the acute disease.  

1:53:21        In my opinion, brain and heart are the most affected Organs of the acute stage of the disease.

1:53:29        Next comes the chronic stage of the disease. I prepared these slides one and a half months back. I just wanted to give you an example;

1:53:35        What is the chronic state of the disease?

1:53:40        This is a picture from a very popular TV series, “The Big Bang Theory” and if anyone has seen this, in this particular scene, Sheldon and Penny, they are driving a car and the car has the yellow engine sign on.

1:53:55        Penny doesn't care. And so, she is driving the car for many, many, many months. So, Sheldon is asking; “Your engine light is on.  You have some problems going on in the engine.”

1:54:09        She says “Oh, the car is driving.  There is no issue at all.” And after some time, the car stops.

1:54:15        So, the chronic state of the disease is happening from a long time back. It is still going on, but you don’t realise it, until and unless you come to a still position. You are sick. You can’t really cope with your life.

1:54:31        The overlapping chronic clinical symptoms among patients, are a lack of muscle energy, altered blood metabolism, allergies, overactive pro-inflammatory immune system, high Interleukins, TNF Alpha (which is very common) Mast Cell Activation and changes in the Gut Microbiota.

1:54:51        Again, this is the hypothesis. This is the way I see the disease. Not necessarily that you agree with me. But I think that these symptoms are associated with the chronicity of the disease.  Now, you can tell me, what difference does it make in a patient’s life, whether it’s the acute stage of the disease, whether it’s the chronic stage of the disease.

1:55:07        I just need a treatment.  But that’s not the case.  If we don’t understand the root cause of the disease, we probably will not be able to treat it properly.

1:55:21        Just to give an example.  Your house is leaking and water is dropping and you call someone and you say “My house is leaking.”

1:55:31        So, the person will tell you, (the first one) “It’s absolutely normal. Many houses leak. If you have a rainy season, many houses leak. Just put a bucket, collect the rainwater and wait for the rain to get over.”  Yes. True. Fine.

1:55:49        But you don’t want this solution. Maybe you call another person and the person says “Let’s check where the water is leaking. The pipe is broken. Let’s repair it.”

1:55:59        This is one more step ahead.  

        The third person might tell you “Oh, the water pipe is broken and we had to repair it. That’s for sure.  Maybe your water pressure is too high and we need to change the water pressure so that there is no further damage to your pipe.”

1:56:17        So, the solution can come in three different ways and you have to decide which solution you want for yourself.  Right?

1:56:25        So, the Mitochondrial dysfunction in acute state of the disease.  Let me explain what can cause mitochondrial dysfunction in acute state.

1:56:33        As I mentioned, the most prominent organs in the body where acute state of the disease can cause mitochondrial dysfunction is brain, or the neuronal cells, muscle cells can also have acute state of the disease. Cardio-myocytes can have ….. and I think one of the most interesting sites is bone marrow which basically is the source of many different type of cells and as you know

1:57:03        that there are many viruses which …… and other pathogens phase (?), lie as latent in this and and if there is a reactivation happens in bone marrow, it can alter the entire immune complex of the body.

1:57:21        So, the productive infection of these organs can cause damage as well as chronic (or leaky) virus reactivation. This is something which clinicians most often not try to understand and to treat this possibility.

1:57:48        If you argue, after the Covid, that SARS-CoV-2 spike protein can stay in your body for years, why is not possible that any other viral protein can stay in your body for years?

1:57:55        Right?  Just a simple argument.  O.K.

        So, this type of acute disease is happening in localised tissue. Probably very hard to detect in the blood.

1:58:09        Herpes Viruses.  One great example; My Lab is focusing on understanding what exactly is the mechanism. Why EBV can cause the acute state of the disease and how the mitochondrial dysfunction can happen.

1:58:23        We know that SARS-CoV-2 is also responsible for mitochondrial dysfunction and there is a connection. We have shown that SARS-CoV-2 infection reactivates herpes viruses and they might act together also.

1:58:37        In my Lab, particularly, we are focussing on Spike Protein of the SARS-CoV-2 and how this protein interacts with Herpes viruses and how, in combination, they can cause mitochondrial dysfunction.

1:58:51        We work on Viral Micro-RNAs. We know that viral micro-RNAs directly target mitochondria and we have recently been focussing a class of proteins called the dUTPase proteins from herpes viruses, and trying to understand how they can cause acute, as well as chronic state of the disease.

1:59:12        Just to give a little bit of data here, when COVID came and patients started to develop Long-Covid, we asked ourselves that this is the best possibility that we can see if herpes viruses are reactivating in these Long-Covid patients.

1:59:38        We started in 2020, July, immediately after the first COVID case came, we isolated the SARS-CoV-2 in our clinic and then we started doing invitro experiments. We saw that SARS-CoV-2 can reactivate herpes virus inside a cell. Then we started to look into the patients.

1:59:56        Now you know that there are a couple of papers in the market which all say that herpes virus reactivation is very common.  But in our own data, which is now available as a preprint, you will see that we started to look into the IgG against different herpes viruses.

2:00:06        So, here we have Healthy Controls, we have Patients, who got COVID but did not develop into Long-Covid, we have M.E/cfs patients, Mild Long-Covid and Severe Long-Covid Patients.

2:00:22        And you can see that we looked into EBV, HSV1 and HHV6.  This is the data which is in the preprint, but we have gone beyond this, but still, you can see that EBV reactivation in M.E/cfs patients is highly significant.

2:00:38        And I can tell you that this is a huge cohort of samples and almost 60% of the M.E/cfs patients have clear signs of EBV reactivation.

2:00:50        There is an increase in Long-Covid EBV, but it’s not significant. In severe Long-Covid patients, we found a little bit high amount of HSV1 and HHV6 has a very interesting trend.  You can see that in M.E/cfs patients in comparison to Healthy Controls, there is high, but it is not statistically significant.

2:01:14        So, we argue that ……. so this is IgG against a specific protein called dUTPase.

        We argue that within six months of getting the COVID infection, if the patients are able to develop an antibody response against that particular protein, this proves that the protein is being produced within the last six months.

2:01:34        Because without the protein, or without the antigen, there will be no antibody response.

2:01:37        So, what is this protein is actually doing and why is the body producing such a strong antibody response so quickly?  There must be something toxic …… things coming from this protein that maybe the body is producing neutralising antibody against it.

2:01:53        With this argument, we tried to look at what this protein is doing inside the cell.

2:01:55        So, what we found is very interesting.  You can argue: “Why EBV is so common?” Why HHV6, HSV1, VZV is not so common in M.E/cfs patients?  Very interesting.

2:02:12        If you compare all of the nine herpes viruses, the dUTPase protein of EBV is the only one which goes to the nucleus.

2:02:23        The rest ….. all eight herpes virus proteins ……. are in the cytoplasm. So, there is a difference in cellular localisation.  That makes EBV special.

2:02:29        Then, one interesting observation here, is that these herpes viruses, particularly EBV, they cause mitochondrial fragmentation and hyperfusion.

        So, mitochondria, after EBV, it’s not even infection, it’s just the one protein of EBV, it causes the mitochondria to become smaller and come together (stick together), to become a clump-like structure, called hyperfusion.  

2:02:54        So, my Lab in Wurzburg, which is still functional, we have two very talented Colleagues, Stefan and Claudia, they are the ones who are leading this project.

2:03:08        Just to give you an example, this is a normal cell (with a control cell basically) you can see the mitochondria look like nicely spread.  These are Primary Human Umbilical Vein Endothelial Cells and if you express the EBV dUTPase, you can see that they are going into the nucleus.

2:03:31        You can see that the mitochondria fragments, they are now like dots, and the majority of the mitochondria are coming to one part of the cell and just clumping.  

2:03:38        Now, what it does, you can actually characterise it. We characterised it, that the mitochondria fragment, because one of the proteins, called the DRP1, it is induced and causes the mitochondria to fragment, and this can be quantified.

2:03:55        One interesting observation, is that only the EBV dUTPase can block the ATP synthesis in cells.

2:04:05        So, it targets the fourth complex of the mitochondria, where the ATP should come out, it actually turns it in and pushes the ATP towards the inside. So, instead of producing, it spends more ATP.  So, it affects the oxidative phosphorylation.  

2:04:25        Now, coming to the chronic state of the disease.  Here the infection directly is not causing the mitochondrial dysfunction. I believe that it is the innate immunity, sorry, the inflammation and the autoimmunity, probably, these are the three important features which are inducing this disease

2:04:42        We believe …… and we already have a preprint which shows that Natural autoantibodies are depleted in patients, which leads to autoimmunity and cause the inflammation, and that inflammation is actually responsible for increased TLR4, Mast Cell Activation and all of the other things.

2:05:01        And mitochondrial dysfunction is very important and we are focusing on how immunoglobulins, how the antibodies in your blood, can cause mitochondrial dysfunction.

2:05:12        Just to give you an example;  We are funded from the BNBF, we have got a grant a couple of years back, together with ME Research UK, we are doing a large study, where we are isolating the immunoglobulins from patients.

2:05:29        So far, we have now done 41 M.E/cfs patients, 16 Long-Covid patients, 40 Healthy Controls and 11 Multiple Sclerosis patients.

2:05:36        We isolated IgG from these patients and what we do?  We take out the IgG, take the IgG and put it into a healthy cell and see if the IgG cause mitochondrial dysfunction.

2:05:41        Now, you can see that the IgG which is isolated from M.E/cfs patients, they do cause mitochondrial dysfunction, rather, serial mitochondrial dysfunction. You can see the mitochondrial architecture is broken down, so more mitochondrial fragmentation.

2:06:04        And you can see that this is happening, because of decrease in Mitofusin One. This is the protein on mitochondria which fuse the mitochondria. So, it goes down.

2:06:13        There is another protein, called PLD6 which is going down, because …...

        These are all the proteins that you need to keep the mitochondria sticking together or fused.

2:06:26        To end this part of my talk, I would like to give a provocative hypothesis. Recently, we have been discussing a recent study coming out of Akiko Iwasaki’s Lab, where they took IgG isolated from Long-Covid patients and put it into mice and they could replicate some of the symptoms.  Not the disease, but some of the symptoms.

2:06:50        I showed you that IgG from M.E/cfs patients can cause mitochondrial dysfunction.

2:06:54        So, all of a sudden that points to maybe there is some antibody in more amount which can cause all of these symptoms.

2:07:00        But it can be the other way around.

2:07:06        Maybe there is something not there, which is not present and that is responsible for causing the disease or the mitochondrial dysfunction. So, it is not always necessary ……..

2:07:18        Just to give you an example; This is a very interesting paper, showing that antibody alone is probably not sufficient to go inside and do something.    

2:07:26        Sometimes, the antigen can bind to the antibody and the antigen / antibody complex is necessary to the job.

2:07:35        And our data suggests that there is a defect in antigen / Antibody complex in these patients and there is ……. it is probably not the more amount of Antibody, rather, it is the less amount of Antibody that is causing the disease.

2:07:45        Why is it important? Because it is important.  If you think you have some Antibody which is more in your body like autoimmunity, an Antibody causing autoimmunity, then you probably try to deplete it, which is a successful treatment strategy in many different things.  

2:08:04        But if it is the other way round, that you don't have anything, you probably have to supplement it, not to deplete it. Okay?  

2:08:11        Again it's a hypothesis. It needs to be proven. We have some evidence for this, but we need to go a long way to prove this.

2:08:18        Just to conclude, the last slide.  We have started working on muscle level also, taking this IgG biobank that we have created and we are putting it onto an organ-on-a-chip model, so, the tiny muscles on a small chip and we are putting this IgG into the muscles and trying to see what type of dysfunctions are happening in the muscles at all the levels and all the things.

2:08:46        This is an ongoing collaboration with Dr Carles Rentero from Barcelona.

2:08:52        So, as I mentioned that we are group, fully focused on M.E/cfs.  I still have two members working in Wurzburg, trying to finish all the work till next year, July.

2:09:03        But I have already built a large group in Riga, fully focusing on 7 to 8 different projects on M.E/cfs, very young talented students, members (actually seven) and we are trying to do as much as possible to understand many different aspects of M.E/cfs.

2:09:16        We are funded by some philanthropic organisations; M.E. Research U.K.,  BNBF.

        Fatigatio came in with 10,000 Euros in the past. But more than money, the moral support, sometimes we researchers need the moral support. There is no one in the world telling us keep working, keep working.

2:09:39        But people like members from Fatigatio keep doing. So, my heart goes to the M.E/cfs patient community.  They are always there. They are always there to support.  So, thank you, all of you for your time and for your patience to listen to my talk and also for having me here.

        Thank you.