Testimony of David Berg
David Berg MS, CLS(NCA),
Director, HEMEX Laboratories, Inc., Phoenix, Arizona.
My presentation today is based on a new laboratory diagnosis of what we call "Immune
System Activation of Coagulation" or ISAC for short. ISAC is a panel of new, high sensitivity,
markers of cascade and platelet activation tests. Many of these tests have been used for research
for about 8 years (Dr. Ken Bauer, Dr. Ken Mann, Univ. Conn.) and have become part of the coag
literature and lectures since then. We have been using part of these assays for the last 5 years,
with the current ISAC Panel established just 2 years ago for the investigation of CFS/FM, fetal
wastage syndrome and related disorders.
Last month on July 21, 2000, here in Wash., DC, Dr. Amold Peckerman, of the VA Medical
Center in East Orange, NJ, stated "Our findings suggest that symptoms of illness in Gulf War
veterans with chronic fatigue are linked to the circulation in a coherent and physiologically
significant way. After the Persian Gulf War, many veterans reported chronic fatigue, memory,
concentration and sleep difficulties, muscle and joint pain, and headaches-a pattern of symptoms
resembling chronic fatigue syndrome, an illness with no known cause. The veterans with chronic
fatigue appear to have a disconnect between cardiovascular stress responses (including blood
pressure) and mental activities. The cause of the disconnect is not clear, but may involve
injury to the brain areas involved with the regulation of cardiovascular activity." We postulate a
connection between these findings and low level activation of coagulation as documented in our
recent studies of CFS/FM and GWI.
The EC is a connecting point between pathogen-activated inflammation and the coagulation
system and is part of the defensive host response. During inflammation, cytokines modulate the
coagulation system by down regulating the expression of thrombomodulin (TM) on EC surfaces
and eliminating the anticoagulant environment by blocking.the activation of Protein C. At the
same time, these cytokines induce expression of Tissue Factor (TF) on the EC surfaces which
promotes a procoagulant environment. Immunoglobulins are formed in response to the
pathogens and cross react with BZ-GPI and Annexin V on EC surfaces, exposing PS. Thus, both
TF and PS promote the binding of the tenase and prothrombinase complexes for the local
generation ofthrombin. Antithrombin should remove the unwanted thrombin, When excess
thrombin is NOT controlled properly, fibrinogen is converted to SFM, which results in fibrin
deposition in these ill patients. This fibrin deposition is small at first, but becomes layers upon
layers over time, leading to blockage of oxygen and nutrients to the tissues around the
capillaries. This is an example of SFM production on a LBA. Increased Lp(a) &lor PAI- 1 can
cause decreased local fibrinolysis by blocking activation of plasminogen to palsmin. This leads
to fibrin buildup instead offibrin removal. Another result offibrin deposition is the effect of
diminishing capillary size which may compromise erythrocyte integrity or impair the rate of
delivery of oxygen and nutrients to the surrounding tissues.
Using the ISAC Panel to determine if Chronic Fatigue Syndrome (CFS) / Fibromyalgia (FM)
could be diagnosed by such, we published these findings in Blood Coagulation & Fibrinolysis
(vol 10, #3, Oct.,1999). The diagnostic criterion was 2 of the 5 tests should be positive for such a
diagnosis. We presented this laboratory data of a hypercoag syndrome in CFS/FM patients
at the AACFS meeting in Cambridge in Oct, 1998. In 1999, we began a study of Gulf War Illness
on sick veterans (n=33) and found similar data again. This data has been accepted for
publication in Blood Coagulation & Fibrinolysis(vol 1 i, #7, Oct.,2000). 67% of the GWI
veterans demonstrated activation of the coagulation system. On3r 1 out of the 33 test subjects
had normal values. This soldier has been on numerous antibiotics for several years. Ail others
Regarding hereditary risk factors, 61% of the GWI veterans had positive risk factors noted
(low AntiThrombin, low Protein C, low Protein S, APC Resistance, high Factor II, high Lp(a),
high PAI-I or high Homocysteine). 8/33 (24 %) were positive for thrombophilia risk factors and
7/33 (21%) of the patients were positive for hypofibrinolysis. 5/33 patients (15%) had a risk
factor in each group. This last combination was either increased Lp(a) gr./or PAI-I with
increased Factor II levels. One patient had a homocysteine level of20.9 (Ref Range: 0-13).
Thirteen of the veterans (27%) had normal protein levels in the hereditary risk factors
screened. Nevertheless, 1 1 of these 13 patients (85%) had 2 or more activated coagulation
markers @ositive ISAC panel results). Three out of this group of 1 1 had increased Protein C or
Protein S levels to compensate for the activated coagulation system. Two patients (6%) that had
no detectable protein abnormalities, but had platelet activation. It is possible that these patients
may have had other protein abnormalities, such as, heparin cofactor II, C4b binding protein,
plasminogen, histadine rich Glycoprotein, factor XII, soluble thrombomodulin, ctysfibrinogen,
and/or tissue factor.
16/33 (48%) had evidence of activation of anticoagulation pathways as demonstrated by
elevated Protein C, Protein S and/or AntiThrombin activity. This is probably a compensatory
response that attempts to down regulate the hypercoagulable state which results from
significantly increased fibrinolysis inhibitors or thrombophilia factors. This has also been
observed in CSF/FM > patients (Berg et al).
In a small subset of GWI veterans tested, those who had positive platelet activation had
positive IgA B2-GPI antibodies, indicating exposure to a pathogen through mucosal membranes,
ie, the nose, mouth, lungs or the GT tract. Further studies of IgA positivity may yield better data
about the concept of an air borne pathogen or mucosal membrane exposure in these veterans.
Two of the ill veterans had low fibrinogen levels and elevated SFM, which indicates
developing DIG. Both of these veterans died during the study.
There is a suggestion that vaccines may be part of the cause of the hypercoagulable state in
veterans. There is most likely a genetic predisposition to developing adverse reactions towards
vaccinations since over 60% of the ill Gulf War veterans in our study have positive hereditary
risk factors. And there may be other contributing factors to the Gulf War illness which may have
caused the illness or worsened the pre-existing disease. Activation of coagulation may be a final
common endpoint for differing etiologies of GWI or CFS in patients \irith such predisposing
Because coagulation activation is the central focus of the GWI, it can become a target for
treatment. Further research into the cause of platelet activation is needed to determine if there is
an infectious etiology. An in depth study of the anti-B2GPI-IgA antibody in the GW veterans and
their families needs to be addressed.
The symptoms of CFS/FM and GWI are very similar. The positive ISAC testing of the GWL
patients parallels the results seen in CFS/FM patients. The hereditary risk profile is also positive
in both. The pathophysiology remains constant, cytokines activating antibodies which bind to the
EC and activate platelets and the coagulation cascade.
Thanks to my colleagues who participated in this study: Dr. Hannan. Dr. Buamzweiger, Dr.
Harrison, Lois Berg, MS, Rosie Rameriz, RN and Demise Nichols, RN.
Thank you for your attention to this presentation.
NOTE: The following was added documentation provided to attendees:
IMMUNE SYSTEM ACTIVATION of COAGULATION (ISAC): Chronic inflammatory
Illnesses associated with a coagulation protein defect.
The Model - A Paradigm Shift:
The model proposes that a majority of individuals diagnosed with certain chronic
inflammatory illnesses, based on clinical criteria, may be potentially defined as or involve Anti
phospholipid Antibody Syndrome (APS) with the endothelial cell (EC) as the disease target.
These patients have a hypercoagulable state demonstrated by increased markers of coagulation
activation and increased blood viscosity due to the generation of Soluble Fibn'n Monomer
(SFM). The CFS I FM process and related processes may be triggered by a variety of pathogens
(CMV, HHVG, Mycopiasma, Chlamydia pneumonia, etc.), or some vaccines, resulting in
pathogen-mediated immune activation that induces antibodies which cross react with EC
protective proteins B,GPI & Annexin V. These antibodies dislodge the protective proteins From
EC surfaces, exposing PhosphatidylSerine (PS) on the EC surfaces in capillary beds.
Pathogens induce inflammatory responses which include cytokine modulation of EC to
down regulate the antithrombotic environment (ThromboModulin, tPA) in favor of
prothrombotic expression of Tissue Factor (TF). TF and PS exposure allows binding of the
coagulation tenase and prothombinase complexes to EC surfaces. This results in thrombin
generation leading to SFM formation. SFM dimerizes easily, increasing blood viscosity and
precipitating out on EC surfaces as fibr'n(oid) deposition, creating local ischemia and pathology,
blocking nutrient and oxygen delivery in the microcirculation. A blood clot does not form
because there is not enough of a thrombin burst to activate Factor XIII to cross link the fibrin
into a clot.
A hereditary defect in a coagulation regulatory protein, such as protein C, protein S, Factor
VL, prothrombin gene mutation, Heparin Cofactor II, tPA, PAI-,, Lp(a), or elevated Factor II, X,
XII, or homocysteine is predispositional in greater than 750r6 of patients. Becawre thL
hypercoagulability does not result in an immediate thrombosis (100% occlusion), but rather in
fibrin deposition (50-95%), we suggest that an appropriate name for this antiphospholipid
antibody process would be Immune System Activation of Coagulation (ISAC) syndrome. This
model provides an explanation for the theapeutic benefits reported with low dose anticoagulant
therapy (heparin or warfarin) in some of these patients.
Diagnoses with published associations: Chronic Fatigue Syndrome/Fibromyalgia
(CFSIFIIII), Infertility (Recurrent Fetal Loss and Fetal Wastage Syndromes), Osteonecrosis of
the Jaw Multiple Sclerosis (MS) and Autism.
Diagnoses under investigation: Crohn's Disease and Inflammatory Dowel Disease (IBD),
Late Lyme Disease, Sjogren's Syndrome (SS), Transient Ischemic Attack, Attention Deficit
Disorder and Parkinsons Disease.
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