Mycobacterium avium subsp. paratuberculosis survival in macrophages from crohn's disease patients

[kiny]

 

[kiny]

I think it's normal that only crohn's disease patients have issues with killing MAP, UC does not have macrophage deficiencies in NOD2, ATG16L1 and IL23R mutations, which severely limit autophagy and the ability to kill mycobacteria.

It's interesting to see if IFX is going to be helpful or detrimental to survival I think. It binds to TNF-alpha and can induce apoptosis of active lymphocytes, but at the same time IFX might limit people's ability to control intracellular pathogens.

 

[rollinstone]

Yea that's a bit of a worry, I know recently Dr Borody has liked the combination of anti map biotics along with IFX... Hopefully it's the right decision

 

[Xiaofa Qin]

I think it's normal that only crohn's disease patients have issues with killing MAP, UC does not have macrophage deficiencies in NOD2, ATG16L1 and IL23R mutations, which severely limit autophagy and the ability to kill mycobacteria.

However, according to the more recent publication by Dr. Saleh A. Naser et al, MAP seems more linked to ulcerative colitis (UC) rather than Crohn’s disease (CD). Using the golden procedure they developed, Dr. Naser’s lab in University of Central Florida (UCF) found viable MAP in the blood of 9/20 (45%) UC, 4/20 (20%) CD and 3/18 (17%) of non-IBD. This has been a “Blind Multi Center Investigation” and thus would be more unbiased.

Here is the article:

Naser, S.A., et al., Culture of Mycobacterium avium subspecies paratuberculosis (MAP) from the Blood of Patients with Crohn’s disease: A Follow-Up Blind Multi Center Investigation. The Open Inflammation Journal, 2009. 2: p. 22-23.

http://www.johnes.org/handouts/files/Naser_3-lab_blind_study_2009.pdf.

 

[kiny]

Oh you can find MAP in blood of controls, you can find it in tab water in hospitals, you can find it in cats, in dogs, in every store you visit, in milk, in water, processed foods, you can find it in the labs where they test biopsies, you can find it in water they use to clean their tools with, it's in the air you breathe, MAP in blood isn't a reliable way to prove or disprove anything, it's literally everywhere in the West. The strains specific to regions and the types of animals who have them actually correlate to the bacteria people harbour, you can tell if someone has strain A that they live in place A, it's that widespread.

I have actually been tested for MAP so has my friend, by PCR, we both had negative, I can go to another lab and they'll test me positive and I can go to another and they will test me negative again. Antibiotics use and medication for crohn's disease actually makes it harder to find MAP in crohn's disease patients than in controls, you'd get subclinical disease. In fact I have linked the study here that showed how much detection changed after infliximab use.

Detection rates are going to drop below controls in people who have been on immunosuppressants. How reliable is basing an argument on detection rates now?

There are immunodeficiencies specific for mycobacteria in crohn's disease, abnormal ifn-y response specific to MAP, autophagy issues specific to intracellular pathogens, genetic predisposition overlapping in 6 out of 8 leprosy loci.

These are not there in UC, UC for me has nothing to do with crohn's disease. Anyone who has looked at pictures that show the transmural disease in crohn's disease or even looked at the biopsies will immediately say they are completely different diseases.

If we base evidence on blood tests trying to detect MAP in people with CD we'll be here all day, it's meaningless since it's everywhere.

We'd be doing the same thing as with H Pylori, trying to disprove it is causative because controls have it too, well sure enough they will have it, it's everywhere, but it can only cause disease is a small subset of people, and a candidate for disease is crohn's disease because the immunodeficiencies and clinical symptoms (althoug still different to PTB) make it a good candidate, UC does not.

In how many people can you culture M Leprae, a mycobacteria too? Do we use that as a conclusion to say they don't have leprosy and let them die? No, you consider the bacteria and treat them, since they have all the clinical symptoms of the disease.

Do I think MAP is causative in crohn's disease? No I don't, but I strongly consider it, and I would never use detection in blood as a way to prove or disprove it because we know how unreliable tests are and we know it's everywhere in the environment and we know that many bacteria do not cause symptoms in person A but will cause disease in person B because of genetics and we know medication for crohn's disease directly influences detection rates. It's unreliable and can not be used as an argument for or against.

 

[kiny]

Also, regarding biopsies, if you've seen a biopsy, they are the size of a dot on your screen. The inflammation in crohn's disease is everywhere across the intestine. Do you really believe a biopsy is a good way to reliably test for an antigen? It's more reliable than a blood test maybe, but is that a good way to test for an antigen when the whole intestine is inflamed? Is that where anyone is going to prove or disprove microbial presence? By testing something taken from the outer side of the mucosa the size of a millimeter?

"It's not MAP because we can't find an intracellular bacteria in this dot . " is that a reasonable thing to say?

 

[Xiaofa Qin]

Thanks kiny for sharing the thoughts. I admired the great efforts you and many other patients in this forum took, trying so hard to understand the diseases. The body is very complex. Apparently, it is not easy to read through the many research papers with the many jargons.

Frankly, my intention is not to provoke sentimental arguments, although I have a lot of strong “scientific” evidences for both sides of the MAP controversy for an endless debate. Rather I think we should ponder thoroughly, deeply and carefully over the many conflicting “facts” to make a more accurate assessment and insightful judgments to figure out the likely true nature of the disease.

I do not think finding MAP in the blood is a trivial thing. The long lasting MAP controversy would actually largely attribute to the scarce of MAP found in the patients, which is in fact in great contrast with the situations in the Johne’s disease, M Leprae and H Pylori. Yes, we still failed to find out the right condition for culturing M Leprae in vitro. However, Gerhard Henrik Armauer Hansen in Norway had announced back in 1873 the discovery of Mycobacterium leprae in the tissues of all sufferers, with just a "new and better" microscope, even without the special stains developed by Albert Neisser and others later (http://en.wikipedia.org/wiki/Gerhard_Armauer_Hansen). This had been also before the discovery of Mycobacterium tuberculosis by Robert Koch in 1882 (http://en.wikipedia.org/wiki/Mycobacterium_tuberculosis) and the discovery of Johne’s disease by Heinrich A. Johne in 1905 (http://en.wikipedia.org/wiki/Paratuberculosis). The existence of H. Pylori (the spiral-shaped bacteria) in the lining of the human stomach had been found by German scientists back to 1875, a century before Barry Marshall and Robin Warren approved they are the key causative factors for peptic ulcers in 1980s (http://en.wikipedia.org/wiki/Helicobacter_pylori) . As we know, large amounts of MAP can easily be found in the feces and tissues of Cattle with Johne’s disease and cultured with the standard methods established long time ago. It is the scarce of MAP in the feces and tissue of Crohn’s disease made the report of successful culture of higher rates of viable MAP in the blood of Crohn’s patients become quite an important event. And only the consistent, reproducible differences between the patients and controls may suggest the existence of a possible link.

I also do not agree with the notion that Crohn’s disease is more closely linked to diseases like leprosy rather than ulcerative colitis. There is no misdiagnosis between CD and leprosy at all. However, no matter how splendid the hospital, how good the doctor and how hard they try, there is always a portion of cases Non-Differentiable as either CD or UC. In addition, CD and UC but not leprosy also shared many similarities in epidemiological distribution, treatments, etc.

 

[kiny]

As we know, large amounts of MAP can easily be found in the feces and tissues of Cattle with Johne’s disease and cultured with the standard methods established long time ago. It is the scarce of MAP in the feces and tissue of Crohn’s disease made the report of successful culture of higher rates of viable MAP in the blood of Crohn’s patients become quite an important event.

Well, cows are not the de-facto comparison that should be used to compare humans with and even then it's quite easy to counter this argument you made against MAP.

In sheep for example, Johne's disease is paucimicrobial, you can not isolate the bacteria in stool or blood, PCR testing and other immunological tests are incredibly unreliable and the best way to know the sheep has Johne's disease is to look at clinical symptoms of the animal's intestine, frankly what people do for crohn's disease.

Are we now going to argue a cow looks more like humans than a sheep. Again a discussion that leads nowhere and arguments that lead nowhere.

I will admit that often strains in humans are bovine strains, but there are other strains too found in humans. You can argue back and forth like this all day long.

And as far as easily detected in cow feces, the rate of detection is 50%, that's half of the cows with PTB who do not show MAP in feces.

May I remind also that the infection and actual clinical symptoms in the intestine of animals is 2 to 10 years difference.

I also do not agree with the notion that Crohn’s disease is more closely linked to diseases like leprosy rather than ulcerative colitis. There is no misdiagnosis between CD and leprosy at all. However, no matter how splendid the hospital, how good the doctor and how hard they try, there is always a portion of cases Non-Differentiable as either CD or UC. In addition, CD and UC but not leprosy also shared many similarities in epidemiological distribution, treatments, etc.

I did not say in my reply that Leprosy was clinically linked to crohn's disease, I mentioned that 6 out of 8 susceptibility loci for leprosy conincide with crohn's disease, which is not the case for UC at all.

Which I will show here (2012 Nature study):

I will also show you that genetically UC is nothing at all like crohn's disease.

NOD2 and Atg genes indicating autophagy deficiencies are exclusive to crohn's disease and IL23R mutation has a different function in both disease.

As far as clinical resemblance, if you ask any pathologist if full cut histology pictures from UC and crohn's disease look alike and he will tell you the diseases are as different as water and fire. Crohn's disease is a disease that features full thickness transmural inflammation in a patchy pattern, UC is non-stop inflammation of the intestinal mucosa easily differentiated during a colonscopy.

Differntiating Intestinal tuberculosis from crohn's disease is much harder than differentiating classic crohn's disease from UC, it requires study of crypts and requires bloodwork and other tests to make a final conclusion, UC and crohn's disease show clinical mucosal differences that can easily be seen by the eye alone.



I don't "think" or claim that MAP is causative in crohn's disease, I just think the arguments against MAP are usually arguments that lead nowhere, or often too broad or misinformed, or people try to brush them off as only of academic important even though lives are at stake.

I was tested negative for MAP with PCR, and even I can stay objective and am completely unwilling to ignore MAP as a causative agent because I know how unreliable testing really is, not only that we discussed this in the lab and negatives often become positives. So when I can stay objective, why can't GI or some researchers, when they themselves have less personal evidence than I have who did the tests with my own blood and am unwilling to accept most counterarguments because they are not arguments, they are misjudged dismissals.

And yes I think some people tend to get emotional when GI or other people straight up dismiss MAP or other agents, because you tell me what the alternative is, a live-long chain on extremely dangerous immunosupressants? Or acknowledge the evidence that there has been a lack of evidence of self-targeted immune response, acknowledge that genetic deficienicies now show bacterial handling deficiencies and acknowledge that this difference to us means the diffrence between life-long medication and a cure.

Maybe if some people had the disease themselves who so vehemently try to argue in our name (not referring to you) trying to dismiss anything that speak in favor of MAP or mycobacteria in general, they would see what a disservice they are doing to the people who suffer from the disease. I really truly hope that this contoversy can be solved without wasting the lives of people for another 10 years because some people are too stubborn to acknowledge each other.

I can ask 1000 GI tomorrow what crohn's disease is and half of them will say it's an autoimmune disease. If I ask all of them which autoantigen is invoking this self-directed response there will not be a single one who will be able to tell me, but ask them about MAP and they all have their reply ready, they're not arguments, they're dismissals and a lack of objectivity, and it's very detrimental to the people who actually suffer from the disease.

 

[Xiaofa Qin]

Thank kiny for making me learn more and think more. Frankly, by nature I do not like to argue with people, but would like to exchange information and opinions to make our thoughts more clear.

Well, cows are not the de-facto comparison that should be used to compare humans with

Yes, there are many differences between human and cow. However, the long lasting MAP controversy seems just largely due to the existence of some similarity between Johne’s disease in cattle and CD in human. As we know, the gut contains in much larger amounts of numerous other bacteria, but none of them caused such a persistent controversy.

In sheep for example, Johne's disease is paucimicrobial, you can not isolate the bacteria in stool or blood, PCR testing and other immunological tests are incredibly unreliable and the best way to know the sheep has Johne's disease is to look at clinical symptoms of the animal's intestine

This statement seems different from what I found. Here is a link from The U.S. Department of Agriculture (USDA) on: Johne’s Disease in Sheep. It divided MAP infection in sheep into 4 stages: silent infection, subclinical disease, clinical disease, and advanced clinical disease. It states “Sheep with Stage II Johne’s disease show no signs but may be shedding the agent in its feces.” and “The Stage IV sheep is weak and emaciated, shedding large numbers of the organism in its feces.” According to the document, blood test like the agar gel immunodiffusion (AGID) has also been an important test that can find 85–100 percent of infected sheep at Stage III and IV, with a low rate of false-positive reactions. It seems once the Johne’s disease in sheep advanced into the stage of clinical symptoms, the disease can readily be diagnosed by fecal or tissue culture, tissue histology and blood tests, and be differentiated from many other diseases with similar symptoms such as caseous lymphadenitis abscesses, dental disease, ovine progressive pneumonia, scrapie, nutritional problems, parasitism, and chronic infections of the lung, liver, or kidney.

Thus the big variation and uncertainty seems much more severely occurred in human studies related to MAP. In my opinion, the fundamental reason might be still the scarce of the bacteria and low level of immune reaction. If the study put a high threshold and strict standard, they may find most results negative; if the study lowered the threshold and standard, they may find some positive even in controls.

I also feel the MAP controversy has lasted too long and the government and IBD professionals should make more effort to solve the issue. I feel the blind multi center investigation by the Center for Disease Control and Prevention (CDC), the University of Central Florida and University of Wisconsin an important approach and thus recommended it in the previous post (#4 in this thread) to read. Hope this kind of efforts should be continued and MAP controversy would be not that difficult to be solved.

genetically UC is nothing at all like crohn's disease.

It seems not very accurate for this statement. According to the table you showed in the post, CD actually shared 5 genes (RIPK2, TNF SF15, C13orf31, NOD2 and IL23R) and UC also shared 2 genes (TNFSF15 and HLA) with leprosy. However, as for the genetic association between CD and UC, the paper states that “110 out of 163 loci are associated with both disease phenotypes. Of the remaining loci, 30 are classified as Crohn’s-disease-specific and 23 as ulcerative-colitis-specific. However, 43 of these 53 loci show the same direction of effect in the non-associated disease”, thus 153 out of 163 genes have a similar effect on both CD and UC. This would represent another view from a different angle.

As far as clinical resemblance, if you ask any pathologist if full cut histology pictures from UC and crohn's disease look alike and he will tell you the diseases are as different as water and fire.
......

Differntiating Intestinal tuberculosis from crohn's disease is much harder than differentiating classic crohn's disease from UC

I think the relationship between two diseases should be mainly determined by its nature rather than the resemblance. Intestinal tuberculosis may resemble Crohn’s disease rather than TB of the lung. However, both intestinal and lung TB can be effective treated by anti TB drugs.

Again, the statements above are just my personal opinion.

 

[kiny]

However, the long lasting MAP controversy seems just largely due to the existence of some similarity between Johne’s disease in cattle and CD in human.

Well if it was only that, the discussion would already be over even for me. You could easily prove everyone wrong.

You could argue:
JD (johne's disease) CD (crohn's disease)

-JD has no fistula, CD does
-JD has no stenosing or fibrosis, CD does
-JD has no perforations of the bowel, CD does
-JD has no abscess, CD does
-JD does not feature much blood, CD does
-JD has no obsctrution, CD does

If you based it on appearance you would have won easily, you could say "it looks kind of like JD, but if you look closer it actually looks nothing like CD", and you're would be right, it looks nothing like JD when you start analysing it.


But you would be ignoring immunological data:

-Crohn's disease overlaps with leprosy in 6 out of 8 loci (7 depending on interpretation), mycobacteria suscpetibility.


-There are very specific macrophage immunodeficienices that make people vulnerable especially to mycobacteria.

-People with AIDS and chronic granulomatous disease are very susceptbile to mycobacteria. Very interestingly, people wtih crohnic granulomatous disease get more crohn's disease than controls.

-There is immunological data that supports mycobacterial infection.

"the antibody responses to three individual mycobacterial antigens in CD patients strengthen the possibility that the observed responses are caused by mycobacterial infection" http://onlinelibrary.wiley.com/doi/10.1046/j.1365-3083.2001.00857.x/abstract;jsessionid=D8FC9A51B947DB7A5CBD6E6615AB30D2.d02t01


-And here a very good study that showed that those CD4T helper Cells that are going to the intestine in response to possible antigen presentation and causing inflammation are reactive to MAP. They took the biopsies incubated them with the MAP antigen and they responded very strongly to MAP in particular, NOT to commensals like so many people are saying.

The discussion for me is no longer. "does JD look like crohn's disease", no it doesn't look exactly like crohn's disease, that discussion is over and what's the point of that discussion, but when you find T cells and immunodeficiencies specific to MAP, actual data that is not open for interpretation, it becomes quite a bit harder to argue against MAP.

 

[kiny]

It seems not very accurate for this statement. According to the table you showed in the post, CD actually shared 5 genes (RIPK2, TNF SF15, C13orf31, NOD2 and IL23R) and UC also shared 2 genes (TNFSF15 and HLA) with leprosy.

come on now

NOD2 is a pure CD dominant gene, not only did the table show, you are ignoring it just to show association

"NOD2/CARD15 genetic variants are associated only with Crohn disease and not with ulcerative colitis"

http://www.ncbi.nlm.nih.gov/pubmed/11385576

http://www.nature.com/nature/journal/v411/n6837/full/411603a0.html

ATG16L1 is associated with crohn's disease and not UC

IL23R is a different mutation in both diseases, you can't just compare them like that.

Those are the biggest 3 associations with CD and you try to argue there is genetic association even though you were the first to throw genetic association overboard a few posts ago since you said it was not strong. The 3 biggest gene associations are different.

RIPK2 and C13orf31 are CD, not UC


UC is a disease that is unlike Crohn's Disease. They have almost nothing in common.

Genetic predisposition is completely different.
Pathology is completely different.
Histology is completely different. Crohn's disease is transmural.
Immunologically it's completely different. Autophagy and macrophage deficiencies are exclusive to CD.

UC also has autoanbitodies against epithelial cells, crohn's disease does not. And those autoantibodies are specific to the colon btw.

Arguing UC is similar to Crohn's disease is like arguing water is quite similar to fire.