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 were positive.

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 genetic makeup.

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.

1. Berg D, Berg LH, Couvaras J, Harrison H. Chronic fatigue syndrome 8/or fibromyalgia as a variation of antiphosphdipid antibody syndrome (APS): An explanatory model and approach to laboratory diagnosis. Blood Coagulation and Fibrinolysis 1999:10 435-438.

7. Buchwald D, Chaney PR Peterson DL, Henry B, Wormsley SE, Geiger A, et al. A chronic illness characterized by fatigue, neurologic and immunologic disorders and active HHV6 infection. Ann Int Med 1992; 116: 103-113.

8. Clipper S, Emr M. Herpes vtrus strain identified as a trigger in multiple sclerosis. NIH National Institute of Neurological Disorders and Stroke, Atlanta, GE; November 24 1997.

9. Wu CA, Shanley JD. Chronic infection of human umbilical vein endothelial cells by HHV6. ] Gen Virol 1998; 79: 1247-1256.

10. Jacob HS, Visser M, Key NS, Goodman JL, Moldow CF, Vercellotti GM. Herpes virus infection of en- dothelium: new insights in atherosclerosis. Trans Am Clin Climatol Assoc 1992; 103: 95-104.

11. Van Dam-Mieras MC, et al. The procoagulant re- sponse of CMV infected endotheliai cells. Thromb Haemost 1992; 68 (3): 364-370.

12. Nicholson AC, Hajjar DP. Herpesviruses in athero-sclerosis and thrombosis: etiologic agents or ubiqui- tous bystandersl Arterioscler Thromb Vase Biol 1998; 18:339-348.

13. Sutheriand MR, Raynor CM, Leenknegt H, Wright JF, Pryzdial EL. Coagulation initiated on herpes- viruses. Proc Narl Acad Sn LISA 1997; 94 (25):13510-13514.

14. Kaburaki J, Kuwana M, Yamamoto M, Kawai S, Ikeda Y. Clinical significance of anti-Annexin V antibodies in patients with SLE. Am ] Hematol 1997; 54: 209- 213.

15. Rand JH, Wu XX, Andree HAM, Lockwood CJ, Culler S, Scher J, Harpel PC. Pregnancy loss in the APS syndrome--a possible thrombogenic mechanism. N Engl] Med 1997; 337 (3): 154-160.

16. Glueck CJ, McMahan RE, Bouquet JE, Tnplett D, Gruppo R, Wang P. Heterozygosity for the Leiden mutation of the factor V gene, a common pathoetiol- ogy for osteonecrosis of the jaw, with thrombophilia augmented by exogenous estrogens. ] Lab Clin Med 1997; 130: 540-543.

17. Berg D, Berg LH, Couvaras J. Is CFS/FM due to an undefined hypercoagulable state brought on by immune activation of coagulation, Does adding anti- coagulant therapy improve CFS/FM patient symptoms:, AACFS Proceedings, Cambridge, MA, 10-12 October 1998. p. 62.

18.Vermyeln J, Hoylaerts MF, Amout J. Antibody- mediated thrombosis. Thromb Haemosr 1997; 78 (1): 420-426.