Medical Sentinel 1999; 4:172-176, the official, peer-reviewed journal of the
Association of American Physicians and Surgeons (AAPS).

Mycoplasmal Infections in Chronic Illnesses: Fibromyalgia and Chronic
Fatigue Syndromes, Gulf War Illness, HIV-AIDS and Rheumatoid Arthritis

http://www.immed.org/publications/infectious_disease/pub3.html

Prof. Garth L. Nicolson, PhD, Marwan Y. Nasralla, PhD, Joerg Haier, MD, PhD,
Robert Erwin, MD, Nancy L. Nicolson, PhD, and Richard Ngwenya, MD
The Institute for Molecular Medicine, 15162 Triton Lane, Huntington Beach,
CA 92649 and James Mobb Immune Enhancement, Harare, Zimbabwe

ABSTRACT Invasive bacterial infections are associated with several acute and
chronic illnesses, including: aerodigestive diseases such as Asthma,
Pneumonia, Inflammatory Bowel Disease; rheumatoid diseases, such as
Rheumatoid Arthritis (RA); immunosuppression diseases such as HIV-AIDS;
genitourinary infections and chronic fatigue illnesses such as Chronic
Fatigue Syndrome (CFS), Fibromyalgia Syndrome (FMS) and Gulf War Illnesses
(GWI). It is now apparent that such infections could be (a) causative, (b)
cofactors or (c) opportunistic agents in a variety of chronic illnesses.
Using Forensic Polymerase Chain Reaction we have looked for the presence of
one class of invasive infection (mycoplasmal infections) inside blood
leukocyte samples from patients with CFS (Myalgic Encephalomyelitis), FMS,
RA and GWI. There was a significant difference between symptomatic CFS, FMS,
GWI and RA patients with positive mycoplasmal infections of any species
(45-63%) and healthy positive controls (~9%) (P<0.001). This difference was
even greater when specific species (M. fermentans, M. hominis, M. penetrans,
M. pneumoniae) were detected. Except for GWI, most patients had multiple
mycoplasmal infections (more than one species of mycoplasma). Patients with
different diagnoses but overlapping signs and symptoms often have
mycoplasmal infections, and such mycoplasma-positive patients generally
respond to multiple cycles of particular antibiotics (doxycycline,
minocycline, ciprofloxacin, azithromycin and clarithromycin). Multiple
cycles of these antibiotics plus nutritional support appear to be necessary
for successful treatment. In addition, immune enhancement and other
supplements appear to help these patients regain their health. Other chronic
infections may also be involved to various degrees with or without
mycoplasmal infections in causing patient morbidity in various chronic
illnesses.

Introduction--Chronic Illnesses

There is growing awareness that many chronic illnesses may have an
infectious nature that is either responsible (causative) for the illness, a
cofactor for the illness or appears as an opportunistic infection(s) that is
responsible for aggravating patient morbidity.1 There are several reasons
for this notion, including the nonrandom or clustered appearance of an
illness, often in immediate family members, the course of the illness and
its response to therapies based on infectious agents. Since chronic
illnesses are often complex, involving multiple, nonspecific, overlapping
signs and symptoms, they are difficult to diagnose and even more difficult
to treat. Most chronic illnesses do not have effective therapies, and
patients rarely recover from their conditions,2 causing in some areas of the
world catastrophic economic problems.

Some chronic illnesses, such as Rheumatoid Arthritis (RA), are well
established in their clinical diagnosis,3 whereas others, such as Chronic
Fatigue Syndrome (CFS, sometimes called Myalgic Encephalomyelitis),
Fibromyalgia Syndrome (FMS) and Gulf War Syndrome or Gulf War Illnesses
(GWI), have rather nonspecific but similar complex, multi-organ signs and
symptoms that overlap or are almost identical.1 In the case of CFS, FMS and
GWI these include: chronic fatigue, headaches, muscle pain and soreness,
nausea, gastrointestinal problems, joint pain and soreness, lymph node pain,
cognitive problems, depression, breathing problems and other signs and
symptoms.4 The major difference between these illnesses appears to be in the
severity of specific signs and symptoms. For example, FMS patients have as
their major complaint muscle and overall pain, soreness and weakness,
whereas CFS patients most often complain of chronic fatigue and joint pain,
stiffness and soreness, but otherwise their complaints usually overlap.
Often these patients have increased sensitivities to various environmental
irritants and enhanced allergic responses. Although chronic fatigue
illnesses have been known for several years, most patients with CFS, FMS,
GWI and in some cases RA have had few treatment options. This may have been
due to the imprecise nature of their diagnoses, which are based primarily on
clinical observations rather than laboratory tests, and a lack of
understanding about the underlying causes of these illnesses or the factors
responsible for patient morbidity.1 These illnesses could have different
initial causes or triggers but similar cofactors or similar opportunistic
infections that cause significant morbidity.

Chronic Illnesses--Overlapping Signs and Symptoms

The multiple signs and symptoms of FMS, CFS and GWI are complex, nonspecific
and completely overlapping (Figure 1), suggesting that these illnesses are
related and not completely separate syndromes.1, 6 In this figure only
differences in the signs and symptoms after the onset of illness are shown,
and the data for FMS and CFS have been combined, because previous studies
indicated that with the exception of muscle pain and tenderness, there was
essentially no difference in patient signs.4 Illness Survey Forms were
analyzed to determine the most common signs and symptoms at the time when
blood was drawn from patients. The intensity of patient signs and symptoms
prior to and after onset of illness was recorded on a 10-point rank scale
(0-10, extreme). The data were arranged by 38 different signs and symptoms
and were considered positive if the value after onset of illness was two or
more points higher than prior to the onset of illness. The data in Figure 1
indicate that patients diagnosed with CFS or FMS had complex signs and
symptoms that were similar to those reported for GWI. In addition, the
presence of rheumatoid signs and symptoms in each of these disorders
indicates that there are also similarities to RA.7 Moreover, it is not
unusual to find immediate family members who display similar signs and
symptoms. For example, there is evidence that GWI has slowly spread to
immediate family members,8 and it is likely that it has also spread to some
degree in the workplace.1 A preliminary survey of approximately 1,200 GWI
families indicated that approximately 77% of spouses and a majority of
children born after the war had signs and symptoms similar or identical to
veterans with GWI.8

In the absence of laboratory tests to the contrary, chronic illnesses are
often misdiagnosed as somatoform disorders caused by stress and other
nonorganic factors.9 Patients with CFS, FMS and GWI usually have cognitive
problems, such as short term memory loss, difficulty concentrating and other
problems, and physicians who find psychological or psychiatric problems in
these patients often decide that these conditions are caused by somatoform
disorders, not organic problems.1 Stress is often mentioned as an important
factor or the important factor in these disorders. Indeed, GWI patients are
often diagnosed with Post Traumatic Stress Disorder (PTSD) in veterans’ and
military hospitals.10 The evidence that has been offered as proof that
stress or PTSD is the source of GWI sickness is the assumption that veterans
must have suffered from stress by virtue of the stressful environment in
which they found themselves during the Gulf War,10 but the veterans
themselves do not feel that stress-related diagnoses are an accurate
portrayal of their illnesses. Most testimony to date refutes the notion that
stress is the major factor in GWI,11 suggesting that stress, albeit
important, is not the cause of GWI.12 But most physicians would agree that
stress can exacerbate chronic illnesses and suppress immune systems,
suggesting that stress plays a secondary not primary role in chronic
illnesses, such as GWI, CFS and FMS.1 However, in the absence of physical or
laboratory tests that can identify possible origins of FMS, CFS or GWI, many
physicians accept that stress is the cause of these chronic illnesses. It
has been only recently that other causes were seriously considered,
including chronic infections.13

Mycoplasmal Infections in CFS, FMS and GWI

We have been particularly interested in the roles of certain chronic
infectious agents in CFS, FMS and GWI, because these microorganisms can
cause most or essentially all of the signs and symptoms found in these
patients.1,14 One of the types of infections that elicited our attention are
microorganisms of the class Molecutes, small bacterial mycoplasmas, lacking
cell walls, that are capable of invading several types of human cells and
are associated with a wide variety of human diseases.14

We have examined the presence of mycoplasmal blood infections in GWI, CFS
and FMS patients. The clinical diagnosis of these disorders was obtained
from referring physicians according to the patients’ major signs and
symptoms. Since the signs and symptoms of CFS and FMS patients completely
overlapped, these patients were therefore considered together (CFS/FMS).1
Blood was collected, shipped over night at 4°C and processed immediately for
PCR after purification of DNA using a Chelex procedure.1,7 Patients’ blood
was analyzed for the presence of mycoplasmal infections in blood leukocytes.
Positive PCR results were confirmed if the PCR product was 717 base pairs in
size using the genus-specific primers (or 850 base pairs for M. fermentans
specific primers, etc.) along with a positive control of the same size in
the same gel, and if a visible band obtained after hybridization with the
internal probe.15 The sensitivity and specificity of the PCR methods were
determined by examining serial dilutions of purified DNA of M. fermentans,
M. pneumoniae, M. penetrans, M. hominis and M. genetalium. Amounts as low as
10 fg of purified DNA were detectable for all species using the genus
primers. The amplification with genus primers produced the expected fragment
size in all tested species, which was confirmed by hybridization with an
inner probe.16

Mycoplasma tests were performed on all patients as described
previously1,7,17 either from Chelex-purified DNA or DNA prepared from whole
blood using a commercial kit. The targeted Mycoplasma spp. sequence was
amplified from DNA extracted from the peripheral blood of 144/203 CFS or FMS
patients (~70%). In 70 healthy subjects positive results for Mycoplasma spp.
were obtained in 6 samples (<9%). The difference between patient and control
groups was significant (p<0.001).16 In addition, two of the 70 controls were
positive for M. fermentans. The ratio between positive and negative patients
was comparable in female and male patients. These results are quite similar
to the results recently published by others.18 Similarly, using
Nucleoprotein Gene Tracking to analyze the blood leukocytes from GWI
patients we found that 91/200 (45%) were positive for mycoplasmal
infections.19,20 In contrast, in nondeployed, healthy adults the incidence
of mycoplasmal infections was 4/62 (~6%).19,20

Patients with FMS or CFS often have multiple mycoplasmal infections, and
probably other chronic infections as well. When we examined CFS/FMS patients
for M. fermentans, M. pneumoniae, M. penetrans, M. hominis infections,
multiple infections were found in over one-half of 93 patients (Figure 2).
CFS/FMS patients had double (over 30%) or triple (over 20%) mycoplasmal
infections, but only when one of the species was M. fermentans or M.
pneumoniae.17 Higher score values for increases in the severity of signs and
symptoms were also found in patients with multiple infections. CFS/FMS
patients infected with different mycoplasma species generally had a longer
history of illness, suggesting that patients may have contracted additional
infections with time.17

In the course of our studies we found that DNA preparation and blood storage
was extremely important in preserving the test samples. Storage of blood
frozen or at 0-4°C resulted in reproducible assay results, whereas storage
at room temperature resulted in loss of PCR signal over time. Within 1-2
days at room temperature, most of the positive samples reverted to negative
results.1 Also, blood drawn in tubes (blue-top) containing citrate and kept
at 0-4°C before the assay yielded better results than other anticoagulants,
unless the samples were frozen in EDTA (purple-top) tubes.

Mycoplasmal Infections in Rheumatoid Diseases

The underlying causes of rheumatoid diseases are not known, but RA and other
autoimmune diseases could be triggered or exacerbated by infectious agents.
It has been known for some time that infectious diseases in some animal
species result in remarkable clinical and pathological similarities to RA
and other rheumatoid diseases. Aerobic and anaerobic intestinal bacteria,
viruses and mycoplasmas have been proposed as important agents in RA.21
Recently there has been increasing evidence that mycoplasmas may play a role
in the initiation or progression of RA.22 Mycoplasmas have been proposed to
interact nonspecifically with B-lymphocytes, resulting in modulation of
immunity, autoimmune reactions and promotion of rheumatoid diseases.23 M.
pneumoniae, M. salivarium and U. urealyticum have also been found in the
joint tissues of patients with rheumatological diseases, suggesting their
pathogenic involvement.24

When we examined RA patients’ blood leukocytes for the presence of
mycoplasmas, we found that approximately one-half were infected with various
species of mycoplasmas.7 The most common species found was M. fermentans,
followed by M. pneumoniae and M. hominis and finally M. penetrans. Similar
to what we found in CFS/FMS patients, there was a high percentage of
multiple mycoplasmal infections in RA patients when one of the species was
M. fermentans.7

Although the precise role of mycoplasmas in RA and other rheumatoid
inflammatory diseases remains unknown, mycoplasmas could be important
cofactors in the development of inflammatory responses and progression of
the disease. As an example of the possible role of mycoplasmas in
rheumatological diseases, M. arthritidis infections in animals can trigger
and exacerbate autoimmune arthritis.25 This mycoplasma can also suppress
T-cells and release substances that act on polymorphonuclear granulocytes,
such as oxygen radicals, chemotactic factors and other substances.26
Mycoplasmal infections can increase proinflammatory cytokines, such as
Interleukin-1, -2 and -6,27 suggesting that they are involved in the
development and possibly progression of rheumatological diseases.

In addition to mycoplasmal infections, other microorganisms have been under
investigation as cofactors or causative agents in rheumatological diseases.
The discovery of EB virus28 and cytomegalovirus29 in the cells of the
synovial lining in RA patients suggested their involvement in RA, possibly
as a cofactor. There are a number of bacteria and viruses that are
candidates in the induction of RA or its progression.30 In support of
bacterial involvement in RA, it has been known for some time that
antibiotics like minocycline can alleviate the clinical signs and symptoms
of RA.31 Although this has been proposed to be due to their
anti-inflammatory activities, these drugs are likely to be acting to
suppress infections of sensitive microorganisms like mycoplasmas.

Mycoplasmal Infections in Immunosuppresive and Autoimmune Diseases

Mycoplasmas have been implicated in the progression of HIV-AIDS. It has been
known for some time that some species of mycoplasmas are associated with
certain terminal human diseases, such as an acute fatal illness found with
certain Mycoplasma fermentans infections in non-AIDS patients.32 Recently,
mycoplasmal infections have attracted attention as a major source of
morbidity in AIDS patients. For example, M. fermentans can cause renal and
CNS complications in patients with AIDS,33 and M. penetrans has also been
found in the respiratory epithelial cells of AIDS patients.34 Other species
of mycoplasmas have also been found in AIDS patients where they have been
associated with disease progression, such as M. prium and M. hominis.32
Montagnier and Blanchard35 have proposed that mycoplasmas are cofactors in
HIV-AIDS, accelerating progression and accounting, at least in part, for
increased susceptibility of AIDS patients to additional infections. In
addition to immune suppression, some of this increased susceptibility may be
the result of mycoplasma-induced host cell membrane damage from toxic
oxygenated products released from intracellular mycoplasmas.36 Also,
mycoplasmas may regulate HIV-LTR-dependent gene expression,37 suggesting
that mycoplasmas may play an important regulatory role in HIV pathogenicity.

There is some preliminary evidence that mycoplasmal infections could be
associated with autoimmune diseases. In some mycoplasma-positive GWI cases
the signs and symptoms of Multiple Sclerosis (MS), Amyotrophic Lateral
Sclerosis (ALS or Lew Gehrig’s Disease), Lupus, Graves’ Disease and other
complex autoimmune diseases have been seen. Such usually rare autoimmune
responses are consistent with certain chronic infections, such as
mycoplasmal infections, that penetrate into nerve cells, synovial cells and
other cell types. These autoimmune signs and symptoms could be caused when
intracellular pathogens, such as mycoplasmas, escape from cellular
compartments and incorporate into their own structures pieces of host cell
membranes that contain important host membrane antigens that can trigger
autoimmune responses. Alternatively, mycoplasma surface components
(‘superantigens’) may directly stimulate autoimmune responses,38 or their
molecular mimicry of host antigens may explain, in part, their ability to
stimulate autoimmunity.39

Mycoplasmal Infections in Other Clinical Conditions

Asthma, airway inflammation, chronic pneumonia and other respiratory
diseases are known to be associated with mycoplasmal infections. For
example, M. pneumoniae is a common cause of upper respiratory
infections,39,40 and severe Asthma is commonly associated with mycoplasmal
infections.41 Recent evidence has shown that certain mycoplasmas, such as M.
fermentans (incognitus strain), are unusually invasive and often found
within respiratory epithelial cells.34

Heart infections (myocarditis, endocarditis, pericarditis and others) are
often due to chronic infections, such as Mycoplasma,42,43 Chlamydia44 and
possibly other infectious agents.

Other species of mycoplasmas are also associated with various illnesses: M.
hominis infections were first found in patients with hypogammaglobulinemia,
and M. genitalium was first isolated from the urogenital tracts of patients
with nongonococcal urethritis.45,46 Although mycoplasmas can exist in the
oral cavity and gut as normal flora, when they penetrate into the blood and
tissues, they can cause a variety of acute or chronic illnesses. These
cell-penetrating species, such as M. penetrans, M. fermentans and M. pirum
among others, can cause complex systemic signs and symptoms. Mycoplasmas are
also very effective at evading the immune system, and synergism with other
infectious agents can occur.14 Similar types of chronic infections caused by
Chlamydia, Brucella, Coxiella or Boriella may also be involved either as
single agents or as complex, multiple infections (see Figure 2) in many of
the diseases discussed above.

Mycoplasmal Infections--Treatment Suggestions

Once mycoplasmal infections have been identified in the white blood cell
fractions of subsets of CFS, FMS, GWI, RA and other patients, they can be
successfully treated. Appropriate treatment with antibiotics should result
in patient improvement and even recovery.6,19,20 The recommended treatments
for mycoplasmal blood infections require long-term antibiotic therapy,
usually multiple 6-week cycles of doxycycline (200-300 mg/day),47
ciprofloxacin (1,500 mg/day), azithromycin (500 mg/day) or clarithromycin
(750-1,000 mg/day).48 Multiple cycles are required, because few patients
recover after only a few cycles, possibly because of the intracellular
locations of mycoplasmas like M. fermentans and M. penetrans, the
slow-growing nature of these microorganisms and their relative drug
sensitivities. For example, of 87 GWI patients that tested positive for
mycoplasmal infections, all patients relapsed after the first 6-week cycle
of antibiotic therapy, but after up to 6 cycles of therapy 69/87 patients
recovered and returned to active duty.19,20 The clinical responses that were
seen were not due to placebo effects, because administration of some
antibiotics, such as penicillins, resulted in patients becoming more not
less symptomatic, and they were not due to immunosuppressive effects that
can occur with some of the recommended antibiotics. Interestingly, CFS, FMS
and GWI patients that slowly recover after several cycles of antibiotics are
generally less environmentally sensitive, suggesting that their immune
systems may be returning to pre-illness states. If such patients had
illnesses that were caused by psychological or psychiatric problems or
solely by chemical exposures, they should not respond to the recommended
antibiotics and slowly recover. In addition, if such treatments were just
reducing autoimmune responses, then patients should relapse after the
treatments are discontinued.1

Patients with CFS, FMS, RA or GWI usually have nutritional and vitamin
deficiencies that must be corrected.48 These patients are often depleted in
vitamins B, C and E and certain minerals. Unfortunately, patients with these
chronic illnesses often have poor absorption. Therefore, high doses of some
vitamins must be used, and others, such as vitamin B complex, must be given
sublingual. Antibiotics that deplete normal gut bacteria can result in
over-growth of less desirable flora, so Lactobacillus acidophillus
supplementation is recommended. In addition, a number of natural remedies
that boost the immune system are available and are potentially useful,
especially during antibiotic therapy or after therapy has been completed.48
One of us (R.N.) has been involved in the development of ancient African and
Chinese natural immune enhancers and cleansers help to restore natural
immunity and absorption. Although these products are known to help AIDS
patients, their clinical effectiveness in GWI/CFS/FMS/RA patients has not
been carefully evaluated. They appear to be useful during therapy to boost
the immune system or after antibiotic therapy in a maintenance program to
prevent relapses.48

Conclusions

We have proposed that chronic infections are an appropriate explanation for
much of the morbidity seen in a rather large subset of CFS, FMS, GWI and RA
patients, and in a variety of other illnesses. Not every patient will have
this as a diagnostic explanation or have the same types of chronic
infections.1,7,17 Some patients may have chemical or radiological exposures
or other environmental problems as an underlying reason for their chronic
signs and symptoms. In these patients, chronic infections may be
opportunistic. In others, somatoform disorders or illnesses caused by
psychological or psychiatric problems may indeed be important. However, in
these patients antibiotics or immune enhancers should have no lasting effect
whatsoever, and they should not recover on such therapies. The
identification of specific infectious agents in the blood of chronically ill
patients may allow many patients with CFS, FMS, GWI or RA and other chronic
diseases to obtain more specific diagnoses and effective treatments for
their illnesses. Finally, patients with cardiopathies, AIDS, respiratory
illnesses and urogenital infections are often infected with Mycoplasma,
Chlamydia, Brucella or other chronic, invasive bacterial and parasitic
infections, and these patients could benefit from appropriate antibiotic and
neutraceutical therapies that alleviate morbidity.

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Prof. Garth L. Nicolson, Drs. Marwan Nasralla, Joerg Haier, Robert Erwin and
Nancy L. Nicolson are affilated with The Institute for Molecular Medicine,
15162 Triton Lane, Huntington Beach, CA 92649-1401, Tel: +1-714-903-2900,
Fax: +1-714-379-2082, website: www.immed.org, email: gnicolson@immed.org;
Dr. Richard Ngwenya is affiliated with the James Mobb Immune Enhancement
Clinics, 132 Josiah Chinamano Ave., Harare, Zimbabwe, Fax: +263-4-739-832.

Figure Legends

Figure 1. Incidence of increase in severity of signs and symptoms in 203
patients with CFS/FMS compared to GWI after the onset of illness. Severity
of signs and symptoms was assessed using a Patient Illness Survey Form that
included 114 signs and symptoms. The intensity of signs and symptoms were
scored by patients on a 10-point scale (0, none; 10, extreme) prior to and
after onset of illness. Scores were determined in each category (3-9
questions) as the sum of differences between values prior to and after onset
of illness divided by the number of questions in the category. Changes in
socre values of 2 or more points were considered relevant.

Figure 2. Incidence of multiple mycoplasmal infections in 93 CFS/FMS
patients. Patients were examined for M. fermentans, M. pneumoniae, M.
penetrans or M. hominis blood infections by Forensic PCR.