Dr. Domenico FIORE
                                                            V.le Madonna delle Grazie, 17
                                                            35028 Piove di Sacco (Padova)
                                                            Tel. e Fax: 049 970 4306

AMYOTROPHIC LATERAL SCLEROSIS:
ETIOLOGY AND IMMUNOPATHOGENESIS

The amyotrophic lateral sclerosis and some other neuropathies without patches are caused by a  re-infection (toxi-infection) from Bordetella Pertussis in subjects with astrocytes non-producers of   II-class HLA-Antigens: fundamentally they all have the same pathogenesys.

  In thirtyfour patients affected by amyotrophic lateral sclerosis (ALS) and in seven patients affected  by other neuropathies without patches (N-PN), I have searched for anti Bordetella Pertussis (BP)  antibodies by the same methodology I used for Multiple Sclerosis (MS): all of them have come out  to be affected by a BP infection taking place (See notes 1, 2). If the diseases under discussion have  the same etiology (a toxi-infection by Bordetella Pertussis), how can we explain the considerable difference in the anatomic-pathologic damages?

From experimental pathology we know that (See notes 3, 4, 5) :

   a.in a specific animal Species, the experimental allergic encephalitis (EAE), in its form considered the experimental model of human MS, may be induced only in breeds with astrocytes which produce II-class HLA-Antigens; it does not develop in the races with astrocytes which do not produce II-class HLA Antigens.
   b.Anti II-class HLA-Antigens Antibodies inhibit EAS onset;
   c.Soluble adhesive molecules (s-ICAM) are present in MS, they are not present in  non-inflammatory neuropathies (included ALS).

  From immunology we know that (See note 6) "the capacity of immune complexes of modifying or  modulating the immune response, both humoral and cellular, is well-known , even if the intimate  mechanisms that rule such processes are still mostly unknown." … "A suppression of the immune  response and of the lymphocyte activation by immune complexes has been known for a long  time.."..

  The underlying mechanisms would be (See note 6) :

       an antigen's "concealment";
       a release of suppression's soluble factors by T and B lymphocytes, when their FC receptors
       are "held" by immune complexes ;
       a competition with the free antigen for surface receptor of T-lymphocytes;
       an indirect suppression, mediated by the activation of fractions of Complement;
       a "blocking" action of immune complexes on macrophages and on T-cytotoxic lymphocytes.

  From microbiology we know that (See note 7) the characters of immunologic response distinguish  endotoxins (Lipopolysaccharide) from other antigens: the response expresses an IgM prolonged  synthesis, sometimes in total absence of IgG (contrary to what usually happens with other  antigens); the rates of these macroglobulins (IgM) vary in a cyclic way due to a phenomenon of  back-control, for which the antigen-antibody complexes that are formed inhibit the further  immune response. If the antigen endures enough time in the host, a new cycle of antibody  synthesis may be produced.

  As a matter of fact, when the immune circulating complexes reach a sufficiently high level, they  inhibit the antibody production; for a certain period no other immune complexes are formed . The  ones already formed (circulating), caught by the Reticuloendothelial System, are little by little  eliminated (the inhibitory effect ceases). In the chronic infections (protracted passage of toxins in  circulation), once the inhibitory effect by ICC has ceased, the production of new antibodies and  the formation of new ICC start again, we come to a new inhibition of antibody production.

  These cycles go on recurring till the toxin production lasts (till the infection lasts). To the  questions we were asked, we may answer that: The early pathogenic mechanisms (pertussis  reinfection in subject with a muco-ciliar barrier defect, BP toxin passage in circulation, immune  circulating complexes formation) are the same described for MS (See notes 1-2). In the two   categories of neuropathies (with patches or without patches) it is the astrocytes' and ICC's roles  (ICC form in all cases) that makes the difference:

       In MS, the astrocytes are producers of II-class HLA-Antigens, and make the endothelia expose adhesion molecules. ICC, "kept" by adhesion molecules, precipitate in the CNS; in circulation, as a rule, they do not reach such high concentrations to become inhibitory.
       In ALS and in other non-patched neuropathies (NPN) astrocytes are not producers of II-class   HLA-Antigens; the endothelia of cerebral vessels do not expose adhesion molecules. Among  immune complexes, the ones which form in the zone of equivalence precipitate in the rhino-sinal mucosa (Arthus Phenomenon); the ones which form in an excess of antigen or in an excess of antibodies (practically, the most part) go on circulating in the blood till they are  kept and destroyed by the Reticuloendothelial System (Spleen and Liver). The persistence in  circulation of most part of ICC which form, leads to their progressive increase, so that in the  end spring the inhibitory mechanisms that ICC themselves trigger off in the production of antibodies. In chronic pertussis infections in subjects with astrocytes non-producers of   II-class HLA-Antigens, during the inhibiting phases from immune complexes (relative lack of antibodies), the BP toxins which go into blood fix them directly on
neuroepithelia: we have
neuropathies without patches. The pathogenic power of the various pertussis toxins (See  notes 1-2) perfectly explains the neuroepithelial damages characteristic of the neuropathies without patches.

  The amyotrophic lateral sclerosis and some other neuropathies without patches are caused by a re-infection (toxi-infection) from Bordetella Pertussis in subjects with astrocytes non-producers of  II-class HLA-Antigens;   For their pathogenesis they may be considered "natural models" of the chronic progressive Multiple Sclerosis treated with immunosuppressors.

  BIBLIOGRAPHY

    1.Fiore D.: Bordetella Petussis Diseases: Acute - Relapse - Chronic. Immunology - Clinic forms -Treatment.- EOS, n°  3-4, vol XXI, 2001. 61-85.
    2.Fiore D.: Encefalo-Medullopatie da Bordetella Pertussis. Atti del XLI Congresso SNO Rimini 2001 - Rivista di NEUROBIOLOGIA, 3/2001, 219-225.
    3.Kimelberg H.K.- Norenberg M.D.: Gli Astrociti. Le Scienze. Anno XXII. Vol XLII, No 25),. 54-62. Giugno 1989.
    4.Troiano M.: Immunopatogenesi della Sclerosi Multipla: ruolo della barriera emato- encefalica. Volume Abstract del
       Congresso SNO. Otranto-2000. 15-16. 2000.
    5.Troiano M. et Altri: Soluble intercellular adhesion molecule.1 … in multiple sclerosis. Neurology 47: 1535-1541.
       1996.
    6.Bombardieri S. - Vitali C.: Malattie da immunocomplessi.
       in Dammacco: Immunologia in Madicina. edi-ermes, Milano, 1989. 588-589
    7.Chedid L. - Parant M.: Lipopolysaccharides et endotoxines. in Le Minor L.- Veron M.: Bactériologie Médicale.
       Flammarion. Paris,1982. 128-129
 

ABC TV News, HEALTH - September 22, 2003
http://abcnews.go.com/wire/Living/ap20030922_1541.html
Lou Gehrig's Rate Higher in Gulf War Vets
Studies Find Twice the Incidence of Lou Gehrig's Disease in Gulf War Veterans As in Non-Veterans
The Associated Press, WASHINGTON Sept. 22 —

Veterans of the 1991 Persian Gulf War were at least twice as likely to be diagnosed with Lou Gehrig's disease as non-Gulf veterans or other people younger than 45, according to studies published Monday. The findings, reached separately, came almost two years after Veterans Affairs Secretary Anthony Principi decided, based on early findings, that the VA would offer health care and other survivor benefits to Gulf War veterans with Lou Gehrig's disease, amyotrophic lateral sclerosis. That marked the first time the government acknowledged a scientific link between service in the Gulf and a specific disease.
 
"The important thing is where do we go from here? We have to conduct more research into ALS to see if we can determine why this happened," Principi said. Principi also said he hopes "we can now increase funding for ALS research" at VA and at other institutions. The VA study and one led by researchers at the University of Texas Southwestern Medical Center in Dallas appear Tuesday in Neurology, a peer-reviewed journal.

Always fatal, the disease causes the gradual death of nerve cells that control muscle movement and results eventually in paralysis and death. Its cause is unknown, and there remains no cure. It affects about 30,000 Americans and is commonly associated with baseball Hall of Famer Lou Gehrig of the New York Yankees, who died of the disease in 1941 at the age of 37.

The VA found 40 veterans with the disease. The University of Texas center's study found 20. Some cases may have overlapped. The Texas researchers did not have access to all records available to VA. VA researchers found that military personnel deployed to the Gulf War region during the conflict stood twice the risk of suffering ALS compared with nondeployed military.

Members of the Army and Air Force had higher risk.

"What we have to ask now is why is there that elevated risk?" said Dr. R.D. Horner, an epidemiologist at the National Institute of Neurological Disorders and Stroke. He led the VA study. The Texas Southwestern study, led by epidemiologist Dr. Robert Haley, determined that 17 of the 20 war veterans with the disease were diagnosed before they turned 45. Of those, 11 have since died.

Haley compared the number of cases of ALS in Gulf War veterans between 1991 and 1998 to the number of cases expected each year in the same age group 45 or younger in the general population. From 1991 to 1994, the number of cases was no different from what would have been expected. But by 1998, the number was almost three times greater than what was expected, Haley said.

Haley emphasized that not every Gulf War veteran will be stricken. Researchers believe that people who contract ALS are susceptible genetically to it, he said. "A lifetime of environmental exposure will build up and give you this disease in your 60s and 70s," Haley said. "What may have happened here is Gulf War veterans were exposed to some unusually toxic exposure that accelerated the process by 30 years."

Almost 700,000 U.S. military personnel were deployed for the conflict, both in the Desert Shield buildup from August 1990 to January 1991 and Desert Storm combat in January-February 1991. Some returned with complaints of unusual illnesses, including fatigue, diarrhea, dizziness and muscle weakness, which have come to be known as Gulf War Syndrome.

No one has been able to pinpoint a cause for the chronic health problems. And while some veterans, advocacy groups and researchers suspect troops were exposed to an environmental toxin or infectious agent, other researchers blame stress.
Copyright 2003 The Associated Press.

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MSNBC - September 22, 2003
http://www.msnbc.com/news/970122.asp?0sl=-32
Gulf War vets risk paralyzing disease
Reuters

Veterans of the 1991 Gulf War may have an unusually high risk of a deadly and incurable nerve disease called ALS, or Lou Gehrig's disease, according to two U.S. studies published on Monday. WHILE ALS is far from common among the veterans, it has appeared more than expected and at younger-than-usual ages, the separate studies found. One of the studies was done by Dr. Robert Haley, of the University of Texas Southwestern Medical Center at Dallas --who has found much if not most of the published medical evidence supporting the idea of Gulf War Syndrome.

A second study by the U.S Department of Veterans Affairs and National Institutes of Health reaches similar conclusions. Both were published in the journal Neurology.

The VA released its preliminary findings in December 2001.

"VA has contacted the Gulf War veterans identified in the study to help them file new claims or to expedite existing claims. We have granted disability to 37 Gulf conflict veterans for ALS," A VA spokesman said. Haley said the finding was significant because it was "only the third real cluster of ALS cases that's ever been documented." Amytrophic lateral sclerosis, also called ALS or motor neuron disease, attacks nerve cells in the brain and spinal cord, leading to muscle weakness, difficulty speaking, swallowing and breathing, and eventually total paralysis.

It affects about 30,000 Americans, and is named after baseball Hall of Fame member Lou Gehrig, who died of ALS. About 5 percent of cases are inherited but most are unexplained. But because ALS occurs at about the same rate globally, experts believe there must be a genetic weakness that underlies the disease. Haley identified 17 Gulf War veterans under 45 who were diagnosed with ALS between 1991 and 1998, 11 of whom have died. None had a family history of ALS or similar diseases.

HIGHER RATE
Haley calculated the expected rate of ALS among this age group and found 1.38 cases of ALS per year would be expected in the Gulf War veteran population in 1998. He found five cases that year.

The VA study found that troops deployed to Saudi Arabia, Kuwait, the United Arab Emirates, Turkey and the Red Sea area had almost twice the risk of ALS as troops who stayed home.  They verified 107 cases of ALS. Of these 40 were from the 696,000 deployed troops and 67 from the nearly 1.8 million not sent overseas. "This study addressed the question, 'Is there a problem with excessive occurrence of ALS among Gulf War veterans?"' said Ronnie Horner of the National Institute of Neurological Disorders and Stroke, who led the second study. "We found the answer to be yes."

Haley noted the studies involved very small numbers of people and did not mean that most or even many Gulf War veterans need to be worried. "The best thinking in the ALS research world is that ALS only occurs in people with a rare genetic susceptibility," Haley said in a telephone interview.  "If you have that genetic makeup and you are exposed to many years of environmental toxins of one kind or another --and no one knows what they are -- then you get the ALS. That is why usually only older people get it."  Haley said Sarin gas "appears to be central cause in Gulf War Syndrome," affecting about one of seven Gulf War veterans.

This may shed light on why ALS occurs.

"One of the prime suspects in civilian ALS is organophosphate pesticides. Guess what Sarin is? It is an organophosphate pesticide for humans," he said.

Earlier this year the Institute of Medicine reported that not enough studies have been done to link pesticides or any other chemicals to Gulf War Syndrome, a poorly defined group of illnesses seen in many veterans of the 1991 conflict.
© 2003 Reuters Limited., MSNBC Terms, Conditions and Privacy ©2003

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BBC News, UK - September 22, 2003
http://news.bbc.co.uk/1/hi/health/3129180.stm
Gulf war linked to motor neurone

Gulf war veterans are more likely to develop motor neurone disease, according to US studies.  It adds to concerns that former servicemen may have been exposed to something during the 1991 conflict which increased their risk of illness. The studies, published in the journal Neurology, found that veterans of the war were three times more likely to develop the disease.  The illness leads to progressive muscle weakness and eventually death. Veterans in the UK and US have reported a variety of symptoms which they blame on exposure either to vaccines given prior to deployment, or some other environmental factor they encountered during the campaign.

Preliminary results from one of the latest studies had already provided  enough evidence of the motor neurone link for US authorities to classify the illness as "attributable to service" and offer compensation.

However, now the results have been published in full - alongside another study that backs these findings.

Three times risk
In this, researchers from The University of Texas Southwestern Medical Center at Dallas looked at statistics on the rates of a type of motor neurone disease called anterior lateral sclerosis - known in the US as Lou Gehrig's disease.  "While a twofold increase in risk may seem impressive, one needs to realise that this is based upon a just a small number of cases."  Dr Michael Rose, Kings College Hospital, London.  They found that rates among the veterans were three times the rates expected in such relatively young people.

Dr Robert Haley, who led the study, said: "The disease occurred in a very abnormal age group - in people in their 20s and 30s instead of 60s and 70s.  "It raises the question whether the condition might have been caused - or triggered prematurely - by unusual environmental exposures in the war." The other study, by the National Institute of Neurological Disorders and Stroke, suggested a two-fold increase in the rate of motor neurone diseases among veterans.

Rare event
The problems with the study arise from the fact that motor neurone is extremely rare in under 45s - so even a small number of cases would represents a substantial increase in risk.  However, Dr Michael Rose, from King's College Hospital in London, said: "While a twofold increase in risk may seem impressive, one needs to realise that this is based upon a just a small number of cases. "Therefore the calculated risk may easily be changed either way if the methodology has any flaws."

Shaun Rusling, the Chairman of the National Gulf Veterans and Families' Association, said that he was aware of six cases of motor neurone disease in relatively young veterans of the conflict.  He said: "When you consider that I have been told that this disease affects only one in 250,000 people, that is very unusual and worrying. "However, the Ministry of Defence has simply fobbed us off about it."
© BBC MMIII

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The ALS Association (Amyotrophic Lateral Sclerosis)
http:www.alsa.org/
New Research Involving Gulf War Veterans Could Provide Insight About ALS
September 22, 2003

Calabasas Hills, CA (September 22) - New research finds that veterans deployed to the Persian Gulf in the 1991 Gulf War have developed ALS (amyotrophic lateral sclerosis) at approximately twice the rate of veterans not deployed, according to a study published in the September 23 issue of Neurology, the scientific journal of the American Academy of Neurology.

The ALS Association (ALSA) played a key role in consulting with the Departments of Defense and Veterans Affairs, and the broader scientific community, in the decision to proceed with the research into the incidence of ALS in veterans of the 1991 Gulf War. ALSA recommended neurologists who have expertise in ALS for involvement in the study and also helped identify patient enrollees.

The study sought to identify all occurrences of ALS in the military after the start of the Gulf War. According to lead study author Ronnie D. Horner, PhD, of the National Institute of Neurological Disorders and Stroke, this study found that military personnel deployed to the Persian Gulf experienced almost twice the incidence of ALS than those who were not deployed to the region.

"The Gulf War ALS study should serve as a source of incremental knowledge in a body of future research to learn more about the occurrence of ALS in military veterans," said Mary Lyon, vice president of patient services. "This information, in turn, can lead to a better understanding of ALS and how one or more environmental exposures may contribute to the disease."

Known as Lou Gehrig's disease, ALS kills brain and spinal cord cells that control muscle movement, resulting in gradual muscle wasting and loss of movement. ALS usually strikes those between the ages of 40 and 70 and affects as many as 30,000 American at a given time.

"The challenge is in understanding what the environmental exposures may be that are responsible for the higher incidence," said Dr. Lucie Bruijn, ALSA science director and vice president. "The hope of course is that this will provide information about the disease mechanism."

The ALS Association also is collaborating with the Department of Veteran Affairs in a nationwide effort to enroll all living veterans with ALS in the National Registry of Veterans with ALS, the first registry to identify and track the health status of veterans with this progressive neurodegenerative disorder. The purpose of the registry is to identify veterans with ALS, make them aware of emerging treatment studies and offer them the opportunity to participate in research into potential causes of the disease. A scientific review committee of ALS experts will evaluate potential studies and recommend those with merit to the registry members. Dr. Bruijn is participating on this review committee.

The study by Dr. Horner was one of two articles that appear in the September 23 issue of Neurology on the topic of ALS in Gulf War veterans. Another article focuses on age of diagnosis and reports that the rate of ALS in young Gulf War veterans was more than two times greater than the general population. The issue also contained an editorial that expressed concern that the degree of excess risk is not convincing because of the small number of ALS cases.

"The study findings are very suggestive, although, as with all scientific research, there are limitations inherent, such as the small number of ALS cases, that must be considered, Lyon observed. "Whatever controversy that may follow publication of this manuscript should only intensify further
inquiry into a possible association between military service and ALS."

"The ALS Association is committed to assisting the Department of Veterans Affairs in identifying veterans who have ALS and who may become the key to a deeper understanding of any links between military service and this disease," Lyon added.
MEDIA CONTACT:
Jeff Snyder
(818) 880-9007, Ext. 220
jeff@alsa-national.org
© 2003 The ALS Association.
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Metallothionein in ALS Motor Neurons

Authors: Kasarskis, Edward J., M.D., Ph.D. Source: Department of Veterans
Affairs_Research and Development, 810 Vermont Ave. N.W., Washington, D.C.,
United States of America. (IRB #91-22026)

MOTOR NEURONS; METALLOTHIONEIN; MERCURY; AMYOTROPHIC LATERAL SCLEROSIS

... The pathological hallmark of ALS is a selective death of motor neurons in the spinal cord and motor cortex. These features of ALS, however, fail to provide insight into its etiology with the result that several theories of etiopathogenesis have been advanced. Our research focus is upon the potential involvement of toxic trace metals in causing the death of motor neurons. Heretofore, studies of toxic metals have only considered the possibility of excessive accumulation of a metal in the brain and spinal cord. Our own work advanced the notion that mercury is present to excess in
ALS patients when compared to age-matched controls based on a multi-element analytical study using neutron activation analysis of several types of tissue. Further studies have suggested that mercury may be localized within spinal motor neurons using photoemulsion histochemistry. Thus it appears that mercury accumulates within the very cells which degenerate in ALS, suggesting that mercury may be a necessary precondition for ALS-type degeneration to occur.

OBJECTIVE: To investigate one aspect of mercury detoxification in ALS. As a prelude, we have ascertained the distribution of metallothionein (MT) in spinal cord by immunocytochemical methods using a polyclonal antibody to a defined epitope present in all forms of human MT. The MTs are a family of structurally-similar, soluble, cysteine-rich, 6-7 kD proteins which detoxify heavy metals by sequestration and also regulate copper and zinc homeostasis. In control subjects, we found MT immunoreactivity localized to the nucleus, cytoplasm, and axonal extensions of spinal motor neurons. In ALS spinal motor neurons, MT immunoreactivity was absent (or greatly reduced) in the
nucleus. These findings open the possibility that abnormalities of MT may be involved in the pathogenesis of ALS. According to this formulation, MT may be structurally altered in ALS, greatly reduced in amount, or diverted from its normal nuclear localization as a result of toxic metal exposure.

PLAN and METHODS: The overall goal of this study is to isolate and sequence the MTs from the spinal cord of controls and compare the results to ALS patients to determine if MTs are altered in composition in ALS. The issue is a complicated one because: a) 6 MT isoforms have been sequenced from human tissues; b) 11 separate, but closely-related MT genes have been found; and c) MT has not been characterized from human spinal cord. To date, we have partially purified MT from bulk samples of control human spinal cord. Methods are in place to complete the purification of MT isoforms and determine their sequence. After dissection of the anterior horn region and subcellular fractionation, we propose to isolate and identify the  nuclear-associated MT isoform in control spinal cord. Strategies have been developed to deal with collateral issues such as the newly described MT-related protein, "GIF". Guided by the results in controls, we will isolate the nuclear-associated MT(s) from ALS spinal cord. As a final test of the hypothesis, we will compare MT isoforms in motor cortex, the other region in which motor neuron degeneration occurs in ALS.

The results of these studies will evaluate the hypothesis that MT is altered in ALS. Finding an abnormality in MT would give considerable support to the concept that toxic metals are involved in the pathogenesis of ALS.

STATUS:  Results/Findings: We have localized metallothionein and mercury to human and rat spinal motorneurons using both monoclonal and polyclonal antibodies. To date, we have identified MT-3 and MT-2 by direct protein sequencing after isolation. We have mapped the...Entry Month: August, 1999 Initial Project Year: 19931001 Secondary Source ID: FEDRIP/200003/004055