Re: Elevated peroxynitrite and depleted glutathione theories may be complementary

[Guest guest]

,

I'm impressed with the work you've done, and honored that you have

put my scribblings on a par with Marty's eight detailed, peer-

reviewed, published papers. (I wonder how he will feel about that!

(:-)) Actually, I have some idea, because we have interacted quite

a bit over the years, and I last talked with him at the AACFS

meeting in January. We even discussed sharing a room there, but he

wasn't too sure after I disclosed that I snore! Even though we do

have some disagreements, we also have a lot in common in terms of

our metabolic approaches, and I have shared information with him

whenever I have found something I think could be useful to him.

I think that Dr. Cheney as well as the Englebienne--de Meirleir-

-U. of Newcastle, Australia group also have some interesting

theories about the etiology and pathogenesis of CFS.

The version of my hypothesis that is on the MEaction site was

written quite a while ago, and I've made some changes in my

thinking, but your summary still contains the essence of the part

that disagrees with Marty's. My objection to Marty's theory has

always been that I don't think it has a good enough front end. I

think we both believe that glutathione gets depleted (there's good

evidence for that), but we differ over which is the cart and which

is the horse in terms of which happens first.

I will give your synthesis of the two schemes some serious thought.

If you want to get Marty's response, you might post your message on

the cfs_research list on , since we're both on that

list, but I don't think he's on this one. I would expect a spirited

response from him, and it would be fun to read!! Thanks.

Rich

> Abstract:

> The two most plausible theories about the etiology and

pathogenesis

> of CFS at this time are: from Dr Pall, the " elevated

> peroxinitrite " theory ( " MP " ), and from Dr Rich Van Konynenburg,

> the " depleted glutathione " theory ( " RVK " ). I will try to

demonstrate

> that the two theories are not mutually exclusive or alternative,

but

> complementary, so that each provides the other with the missing

> pieces it needs to completely solve the CFS puzzle.

>

> Introduction:

> First I will summarize both hypotheses according to their proposed

> sequence of causes and effects, with " -> " indicating a cause ->

> effect relationship.

>

> MP theory:

> (from

http://molecular.biosciences.wsu.edu/Faculty/pall/pall_cfs.htm )

>

> M1. Stressors (infections, physical trauma, psychological trauma) -

>

> M2. Excessive production of inflammatory cytokines ->

> M3. Induction of iNOS ->

> M4. Production of excessive amounts of NO ->

> M5. Production of excessive amounts of ONOO- ->

> M6. Impairment of ATP production, depletion of GSH, etc.

>

> RVK theory:

> (from http://www.meactionuk.org.uk/hypothesis.html )

>

> R1. Stressors (emotional, physical, chemical, and biological) and

> diet low in sulfur-containing amino acids ->

> R2. Depletion of GSH levels ->

> R3. Excessive production of O2- ->

> R4. Production of excessive amounts of ONOO- ->

> R5. Impairment of ATP production, etc.

>

> Discussion:

>

> In the MP theory, M4 is necessary but not sufficient for causing

M5,

> because an excessive production of ONOO needs elevated levels of

both

> NO and O2-. This is consistent with the fact that not every

person

> exposed to excessive production of inflammatory cytokines develops

> CFS. The also needed elevated O2- level, when present, is

probably

> the result of the sequence of events postulated by the RVK theory.

>

> Analogously, in the RVK theory, R3 is necessary but not sufficient

> for causing R4. This would be consistent with the fact that not

> every person exposed to depletion of GSH levels and consequent

> excessive production of O2- develops CFS (if that were actually a

> fact, which I am not in the possition to definitely assert, but I

> very much suspect it is). The also needed elevated NO level, when

> present, is probably the result of the sequence of events

postulated

> by the MP theory.

>

> The fact that normal levels of NO produced by eNOS and nNOS would

not

> suffice for causing R4 (and so that iNOS expression would be

> necessary) is supported by the strong differences in NO levels and

> timeframes when generated by iNOS as opposed to eNOS or nNOS, as

> discussed in the paper at http://www.yourhair.com/pr/tox.htm

> (please do not dismiss it just because of its not very serious

URL)

>

> " The signal molecule NO2 is synthesized on demand, after enzyme

> activation, by constitutively expressed NO synthases (NOS) for

short

> periods of time (seconds to minutes). The killer molecule NO is

> synthesized by an inducible NOS that, once expressed, produces NO

for

> long periods of time (hours to days). According to calculations,

the

> major differences between cNOS and iNOS activities do not reside

in

> the concentrations of NO generated per enzyme, but rather in the

> duration of NO produced (1). In addition, the iNOS protein content

in

> fully activated cells may be higher than the cNOS content. Thus,

> cytotoxicity usually correlates with the product of iNOS and not

with

> the product of the two cNOS (with possible exceptions in brain

> injury). Thus, regulated pulses versus constant unregulated NO

> synthesis differentiates between the messenger and the killer

> properties of NO. "

>

> It should be noted too that ONOO- impairs ATP production not just

at

> the Krebs cycle but also at several sites of mitochondrial

> respiration, as discussed in

> http://www.bioc.cam.ac.uk/brown/research-NO.html

>

> Conclusion and implications for treatments:

>

> Thus, the etiology of CFS is best explained by the combination of

> both theories, each dealing with one of the components needed to

> produce ONOO-: NO and O2-. Therefore, we could speak of a unified

> theory of CFS etiology (the MPRVK theory?).

>

> Since both theories fit with each other, so should do the courses

of

> treatment proposed by both. For instance, the main component of

> treatment in the RVK theory (supplying a nondenatured whey protein

> supplement to rebuild GSH levels) fits in the MP theory in two

> places, since GSH scavenges both O2- and ONOO-.

>

> Therefore, if we come to think of a unified theory, the unified

> treatment should consist in principle of the combination (logical

OR)

> of the treatments according to both theories, with at least one

> notable exception, which is:

>

> The RVK theory proposes arginine supplementation. Since arginine

is

> the main substrate for iNOS activity (NO production), its

> supplementation should be delayed till the levels of iNOS have

> returned to normal.

>

> (RECovering From Cfs)

[Guest guest]

,

I'm slowly working through your synthesis of Marty's theory and my

hypothesis. Concerning only the point from your post that I've

quoted below, I have actually been aware of this, and I think Marty

mentioned it in his first paper on his theory. The reason I focused

on the action of peroxynitrite on aconitase in the Krebs cycle was

because of the reports from the Australian University of Newcastle

group that two of the main features they saw in the analysis of

urine from PWCs were elevated citric acid and lower than normal 2-

oxo-glutaric (alpha ketoglutaric)acid. I have also seen this in

several urinary organic acids test reports that individual PWCs have

shared with me. From these results, based on some information from

Dr. Cheney that this somehow involved glutathione deficiency, I

reasoned that there must be a partial blockade between these two

metabolites in the Krebs cycle, since that's the only place citric

acid occurs in substantial amounts, as far as I know. There are two

enzymes located between these two metabolites: aconitase and

isocitrate dehydrogenase. Since I knew that aconitase is inhibited

by peroxynitrite and that glutathione inhibits the formation of

peroxynitrite, I opted for that explanation. However, in examining

this situation again, I see that if the complexes in the respiratory

chain are also blocked, it should cause a pileup of NADH, which in

turn can be expected to inhibit isocitrate dehydrogenase. So this

could also explain these urine organic acid results. A clue to what

is going on may be found by looking at the intermediate metabolite

between aconitase and isocitrate dehydrogenase in the Krebs cycle,

which is isocitrate. In the urine organic acid analysis reports

I've seen, this is usually (but not always) at normal levels. This

suggests to me that perhaps both these enzymes are inhibited, and

the inhibition matches well enough that isocitrate usually remains

in the normal range. So I think the available evidence is consistent

with your point, and peroxynitrite may be blocking both aconitase

and the complexes in the respiratory chain.

If the complexes in the respiratory chain are being significantly

blocked, this could be an important issue for determining whether

the cell operates primarily on aerobic glycolysis or anaerobic

glycolysis, given that its Krebs cycles are partially blockaded at

aconitase. If NADH builds up, one would expect quite a bit of

reduction of pyruvate to lactate, i.e. anaerobic glycolysis, and the

burning muscles that some PWCs report may be evidence for this.

This is a significant point, because even though both aerobic and

anaerobic glycolysis produce far less ATP per molecule of glucose

than does the Krebs cycle, the aerobic mode still produces

substantially more than the anaerobic mode, and this could make a

difference in how much energy the PWC.s skeletal muscles can develop.

Thanks again, , and I'll be studying what you've said some more.

Rich

> It should be noted too that ONOO- impairs ATP production not just

at

> the Krebs cycle but also at several sites of mitochondrial

> respiration, as discussed in

> http://www.bioc.cam.ac.uk/brown/research-NO.html

[Guest guest]

,

Thanks for all the abstracts and the arguments. I'll ponder it all

and respond as I can find the time to do the necessary studying. I

appreciate your interest in this. It's very stimulating to me to

interact on the technical issues and to try to hammer out what's

really true. I have an engineering--applied science background

myself, so I have some idea of where you're coming from. Are you a

Chem E.? You seem to have an appreciation of reaction constants. I

think an engineering background is very helpful in working on CFS,

because a " systems approach " seems to be needed in trying to pull all

the aspects together. Most of the professional CFS researchers have

a reductionist orientation and stay inside their specialty boxes,

which limits the rate of progress quite a bit. I think I understand

why they do that (They need to get funded, and the peer-review

process in biomedicine is brutal to people who don't stay in their

boxes. It's safer to propose incremental advances from known

science.), but it helps to have a few mavericks stirring the pot.

I'm retired, so I don't have to get grants funded, and that's very

freeing. Of course, I can't pay for experimentation, either, and

that limits my ability to test hypotheses. I hope to stimulate some

of the funded people to do some relevant experiments and

observations. So far, I think most of them are focussing on the

neurology, endocrinology and immunology of CFS and the interactions

between them. This is good basic research, but it doesn't get at the

main part of the pathogenesis, in my view. I gather that you believe

that the metabolism is crucial in this, also.

I forwarded your initial message to Marty. If you get it onto the

cfs_research list, I'm sure he will engage you in discussion. Marty

is a professor of biochemistry at Washington State in Pullman.

Rich

> >

> > > It should be noted too that ONOO- impairs ATP production not

just

> > at

> > > the Krebs cycle but also at several sites of mitochondrial

> > > respiration, as discussed in

> > > http://www.bioc.cam.ac.uk/brown/research-NO.html

[Guest guest]

,

> > ,

> >

> > I'm impressed with the work you've done,

>

> Thanks!

>

> > My objection to Marty's theory has

> > always been that I don't think it has a good enough front end. I

> > think we both believe that glutathione gets depleted (there's

good

> > evidence for that), but we differ over which is the cart and

which

> > is the horse in terms of which happens first.

>

> It could even be that both happen more or less simultaneously: I

> forgot to mention in my first post that the case for a unified

theory

> was strengthened by the fact that the stressors in Marty's theory

and

> those in yours are pretty much the same.

Right, I understand that (we are both working from the same published

papers that say PWCs report a history of these stressors prior to the

onset of their illness), and it may be true that there is some

simultaneous stuff going on even this early in the pathogenesis. It

certainly does branch out as it proceeds along! I have been

proceeding on an Occam's Razor basis, trying to use the simplest

hypothesis that accounts for the facts. As you say, it may be

necessary to invoke both glutathione depletion and a stimulation of

NO production to account for what goes on. I think we are going to

have to get quantitative to sort out what's actually happening, since

we don't know whether NO or superoxide is the limiting species in the

formation of peroxynitrite. It's conceivable that NO is already

present in sufficiency, and only the rise in superoxide is needed to

produce enough peroxynitrite to insert the partial blockades, or

maybe both need to come up. I think we have to look at the relevant

concentrations, equilibrium constants, is constants, etc., if

they are even known, in order to decide about this.

I should tell you that I have modified my thinking since I wrote the

summary you read to include an initial long-term cortisol and

adrenaline output by the adrenal glands in response to the long-term

stress load. The adrenaline self-oxidizes to adrenochrome, and that

contributes to the depletion of glutathione.

>

> Now, from a somewhat more practical viewpoint, let me change from

the

> cart and horse analogy to another: you have a field plagued with

> snakes and their eggs. In order to clean the field, you have to

> destroy both, no matter which came first. So, it's crucial to BOTH

> rebuild GSH levels AND lower NO production and scavenge ONOO-.

I agree with that. But let me say that I have learned the hard way

that it is not possible to proceed directly from a knowledge (or

hypothesis) about pathogenesis to an optimum treatment protocol. I

suggest that you read my recent message # 58291 to Marcia in this

regard, as well as my Strawman Treatment Protocol found under my name

in the Links section of this list. There are vicious cycles that

come into play, and we are dealing with the mathematical discipline

that is these days called " complexity. "

>

> > If you want to get Marty's response, you might post your message

on

> > the cfs_research list on , since we're both on that

> > list, but I don't think he's on this one. I would expect a

> spirited

> > response from him, and it would be fun to read!!

>

> Have just done it. BTW, I added a comment tthere, which might also

> be relevant here: I gave my post the form of a pseudo paper not

> pretending any scientific status (I am an engineer), but because I

> found it a convenient way to structure my thoughts.

Fair enough. I haven't seen your message come up yet on the research

list. You might want to check on it again.

>

>

Rich

[Guest guest]

I developed the Nitric Oxide/Peroxynitrite Theory of CFS long before

Mall. I abandoned that effort because I realized you could

take the scientific research and twist it to fit almost any pattern

of illness. There was just no way to tell if the chicken or the egg

came first.

I now favor an HPA axis problem (failure to respond to stress

properly), maybe due to a virus or chemical agents or to mercury or

even a bacteria. In my opinion, there can be tens of reasons for a

weak adrenal response to stress. In fact, " weak adrenals " have never

been accepted by the medical establishment. According to most

doctors, you either have full blown 's Disease or your

adrenals are healthy, which I think is big mistake.

I think the best evidence for a falure in stress response as the

cause of CFS is evident by the fact that most PWCs do great if they

do nothing at all and don't have any crisis to deal with. If we could

live our lives like we were on a dream vacation then most of us would

not even know we were sick. We get sick when we are forced to deal

with the stress of everyday life. The more stress we must deal with,

the sickier we get. In my opinion, CFS is nothing more than a failure

of the stress response system which will manifest itself differently

is different folks.

Much more research needs to be done to help PWCs with their weak

adrenal output. We need help to learn how to supplement the HPA axis

and get around feedback. HPA axis feedback problems is what stumps

most everyone that tries to use low doses of hydrocortisone.

I believe we can learn to manage our illness much better if we just

had some good help in the area of HPA axis research.

Kind regards

Dave

> > > > ,

> > >

> > > > My objection to Marty's theory has

> > > > always been that I don't think it has a good enough front

end.

> I

> > > > think we both believe that glutathione gets depleted (there's

> > good

> > > > evidence for that), but we differ over which is the cart and

> > which

> > > > is the horse in terms of which happens first.

> > >

> > > It could even be that both happen more or less simultaneously:

I

> > > forgot to mention in my first post that the case for a unified

> > theory

> > > was strengthened by the fact that the stressors in Marty's

theory

> > and

> > > those in yours are pretty much the same.

> >

> >

> > Right, I understand that (we are both working from the same

> published

> > papers that say PWCs report a history of these stressors prior to

> the

> > onset of their illness), and it may be true that there is some

> > simultaneous stuff going on even this early in the pathogenesis.

> It

> > certainly does branch out as it proceeds along! I have been

> > proceeding on an Occam's Razor basis, trying to use the simplest

> > hypothesis that accounts for the facts. As you say, it may be

> > necessary to invoke both glutathione depletion and a stimulation

of

> > NO production to account for what goes on. I think we are going

to

> > have to get quantitative to sort out what's actually happening,

> since

> > we don't know whether NO or superoxide is the limiting species in

> the

> > formation of peroxynitrite.

>

> > It's conceivable that NO is already

> > present in sufficiency, and only the rise in superoxide is needed

> to

> > produce enough peroxynitrite to insert the partial blockades, or

> > maybe both need to come up. I think we have to look at the

> relevant

> > concentrations, equilibrium constants, is constants, etc.,

> if

> > they are even known, in order to decide about this.

>

> IMHO, before getting quantitative, we should keep in mind a couple

of

> key concepts from your excellent post on 2000/03/07 at alt.med.cfs:

>

> 1. CFS results from a permanent blockade *anywhere* along the chain

> of energy (ATP) production.

> 2. From 1., it follows that there is more than one root cause of

CFS

> among the PWC population, and consequently there are several

subsets

> of them.

>

> A most clear example of 2. is the case at:

> http://www.cfspages.com/story.html

>

> Now, I would advance a bit further. From the following facts:

>

> a. ONOO- can block the Krebs cycle and the respiratory chain

>

> b. NO itself can block the respiratory chain, from the study

> J Neurochem 2000 Aug;75(2):694-700

> Astrocyte-derived nitric oxide causes both reversible and

> irreversible damage to the neuronal mitochondrial respiratory chain.

> VC, Sharpe MA, JB, Heales SJ.

>

> c. ONOO- needs NO and O2- to form

>

> d. Low GSH levels will allow high levels of NO, O2-, and ONOO-

>

> We can hypothesize that the largest portion of the PWC population

may

> not be split into just two discrete, clearly defined subsets: the

low-

> GSH and the high-NO ones. Rather, it can be a continuum like

> {(1:0), ... , (0.5:0.5), ... , (0:1)} where the first number of a

> pair reflects the relative importance of the low GSH cause and the

> second that of the high NO cause. (Both numbers real and the sum=1)

>

> >

> > I should tell you that I have modified my thinking since I wrote

> the

> > summary you read to include an initial long-term cortisol and

> > adrenaline output by the adrenal glands in response to the long-

> term

> > stress load. The adrenaline self-oxidizes to adrenochrome, and

> that

> > contributes to the depletion of glutathione.

>

> Most plausible.

>

> >

> > I haven't seen your message come up yet on the research

> > list. You might want to check on it again.

>

> Nothing seems to appear, only messages from Jan van Roijen.

>

>

[Guest guest]

''I think the best evidence for a falure in stress response as the

cause of CFS is evident by the fact that most PWCs do great if they

do nothing at all and don't have any crisis to deal with.''

Hi Dave, I'm interested in your ideas and I agree mostly, except

one tiny little problem.... Didn't you know people with M.E/CFIDS

have overwhelming exhaustion at REST....feeling like they have

FLU at REST. Nausea at REST, chronic pain, dizzyness, breathing

problems, heart problems, at REST. Sure it gets X10 worse on exhertion

I totally agree, it's just we have the symptoms at rest 24/7 not just

when were' stressed, so that rather makes your theory rather flawed?! lol.

You said 'PWC'S do 'GREAT' if they do nothing at all.

Err........ that's a big WTH in my opinion, and totally false.

If that was correct why are 25% of people severly affected/housebound?

(When they aren't stressed). What does everyone else think?

I guess if you class mild CFS as M.E/CFIDS though ,I'd agree with you

Dave!

Ben.

-----

[Guest guest]

> You said 'PWC'S do 'GREAT' if they do nothing at all.

> Err........ that's a big WTH in my opinion, and totally false.

> If that was correct why are 25% of people severly affected/housebound?

> (When they aren't stressed). What does everyone else think?

>

> I guess if you class mild CFS as M.E/CFIDS though ,I'd agree with you

> Dave!

>

> Ben.

> -----

Ben, I have to agree with you. My symptoms are constant 24/7. Of course when you

add any stress and you have so little resources to work with, it is going to

make one feel worse. But there are no

circumstances, be it vacation/rest/play, etc that make my CFS symptoms go away.

Would that it were true! At least I'd have had some good days these last

decades!

I suppose its possible that there could be a subset that is fine, only has cfs

under stressful conditions and then show symptoms, altho this is not my case. I

would not take licorice because at

this point my blood pressure is borderline high (early days of CFS was 90/50,

now 142/92, so things do change as the years tick by) and licorice can elevate

blood pressure. Don't think its a good

idea to rec. that as a one size fits all treatment.

JMO

Marcia

[Guest guest]

I guess if you class mild CFS as M.E/CFIDS though ,I'd agree with you

Dave!

Ben.

-----

Hi Ben

I agree with you here - my symptoms never go away. The muscle

pain/twitching/weakness and tingling in feet, the feeling of being ill and

really run down, swollen glands, sore throats, chronic insomnia, and sinus pain

(cos I have chronic sinusitis too)

All of these symptoms are worse with exercise of course but remain no matter

how much I rest.

I must add though that in the couple of years of my illness when I was not

severely affected I did have periods when I felt almost normal as long as I

didn't exercise.

[Guest guest]

Dave,

I got back five days ago from a dream vacation -- two weeks cruising the

Baltic with no worries, no mail, paper or electronic, no phone calls and

everything done for me. I've been completely shattered and I'm hoping

today to get out of the house for the first time. Some of us have

post-exertional fatigue and musculoskeletal pains. By comparison, the

effect of stress for us is not so great.

Rob

----- Original Message -----

From: " D " <dwms02@...>

SNIP

If we could

live our lives like we were on a dream vacation then most of us would

not even know we were sick. We get sick when we are forced to deal

with the stress of everyday life. The more stress we must deal with,

the sickier we get. In my opinion, CFS is nothing more than a failure

of the stress response system which will manifest itself differently

is different folks.

Dave

[Guest guest]

Ben, I can't speak for Dave, but you ask, " what does everyone else

think? " , so here goes. There was a study done on PWCs that showed

that the adrenal gland was only 50% the size for PWCs compared to

controls. I think that once you 'get' CFS, the damage has been done,

and maybe the worse the adrenals are, the worse the symptoms are.

I have never heard of anyone getting CFS who lived a life that

was completely devoid of stress. Wealthy people (read Incline

Village), can be under as much or more stress than boat captains,

stockbrokers, etc. Also, as Dave says, it is the *individual's*

response to stress (the HPA axis) that is crucial. I have never had

a relapse or gotten worse when I was on vacation.

Mike C.

> when were' stressed, so that rather makes your theory rather

flawed?! lol.

>

> You said 'PWC'S do 'GREAT' if they do nothing at all.

> Err........ that's a big WTH in my opinion, and totally false.

> If that was correct why are 25% of people severly

affected/housebound?

> (When they aren't stressed). What does everyone else think?

>

> I guess if you class mild CFS as M.E/CFIDS though ,I'd agree with

you

> Dave!

>

> Ben.

[Guest guest]

I know both sides of this, because many times I have been in the camp of " feel

lousy all the time " while at other times " feel ok as long as I don't do

anything. " I know that we are not all the same, but I highly encourage anyone

who feels lousy all the time to look for infections. Every time I have been in

the " feel lousy all the time " camp, I have had untreated viral and bacterial

infections. When I am treating the infections and they are under control, then

I am in the " feel ok as long as I don't do much " camp. It is much less

miserable to be in the second camp.

Doris

----- Original Message -----

Didn't you know people with M.E/CFIDS

have overwhelming exhaustion at REST....feeling like they have

FLU at REST. Nausea at REST, chronic pain, dizzyness, breathing

problems, heart problems, at REST. Sure it gets X10 worse on exhertion

I totally agree, it's just we have the symptoms at rest 24/7 not just

when were' stressed, so that rather makes your theory rather flawed?! lol.