PS about prednisone

T's regular pediatrician had something very interesting to say about my prednisone incident, which I don't think I've mentioned here yet. My husband is actually the one who spoke with her, but I think I've gotten all the major details correct.

According to my husband, when he brought up "the incident" with her (discussed previously in these posts), she was completely unsurprised. In fact, she told him that she had had another patient some time back who tried prednisone, and that it had worked marvels. However, there had been side effects, and she did not necessarily think it was worth it. She said that due to the side effects, they wouldn't use the prednisone at Emory, but she thought her patient had traveled somewhere else.

I'm a little unclear as to whether this patient was forced to discontinue due to the side effects, but the pediatrician says that the patient did retain some of the gains after stopping the prednisone.

I wish I knew more, but I'm not sure if our pediatrician really knows much more than that. If it's true, of course, I'm wondering why she never mentioned it before??

Also, what is it that might make it work, if it does? The folks at Johns Hopkins I thought were very certain that it wouldn't affect the inflammation that they saw in the tissue samples, although maybe I need to go back and read that more closely. I find it so striking, though, that elsewhere I read that prednisone is supposedly helpful for the kind of inflammation involved in asthma because it actually turns off the genes that trigger the release of the inflammatory chemicals.

My friend the infectious diseases doc also thought for that reason that it makes perfect sense that prednisone could have an immediate beneficial effect of this sort (not that she had any idea whether it did or not, you understand -- she is an HIV specialist, this is not her area) -- so it is hard for me to let go of this idea.

But still, assuming it's not that .... could prednisone have a hormonal effect rather than an anti-inflammatory effect (if those are even separate things)? Somehow, prednisone mimics cortisol in some sort of way. And I have read that autistic individuals appear to not experience the cortisol spike in the morning that others do.

I also read somewhere that cortisol has some sort of effect on calcium channels, which have also been implicated in autism, maybe that is relevant?

I think there's a lot of other stuff about cortisol and autism out there, and I just can't remember it all. But could there be some connection there?

I wish I understood all of these things so I could see how they all fit together ....

more on prednisone, inflammation

I actually just discovered some FAQs on the website of the Johns Hopkins Neuroimmunopathology website about inflammation in autistic individuals and it was VERY informative! I wish I had found it first! Here's my Cliff Notes version:

1) There is inflammation in the brains of autistic individuals, and it is chronic. Maybe not all of them, but many of them.

2) Inflammation can be both good and bad, because it is a way to repair. It could be that the inflammation is in response to something else that is bad.

3) Most of the inflammation is in the cerebellum, predominantly in the Purkinje cell layer and the granular cell layer.

4) They characterize their findings as "consistent with an active and ongoing postnatal process of neurodegeneration and neuroinflammation" -- i.e., they don't know for sure that is what is going on, but that is what they suspect.

5) Prednisone and other steroids would not have any impact on the particular kind of inflammation that they found. Their study did not find evidence of the kind of inflammation that prednisone and other steroids addresses.

So this would seem to suggest that if the Prednisone was responsible for the astonishing things I saw in T last week, it is not due to an anti-inflammatory effect.

However, I am nonetheless extremely troubled by these findings. It is extremely upsetting. These FAQs are making comparisons to horrible conditions like HIV dementia, multiple sclerosis, ALS and stroke. The idea that this could be going on in my child's brain is, I will admit, making me feel rather panicky.

It is so hard for me to believe that this is coincidental when my son has also been having breathing problems that are also apparently caused by excessive inflammation.

And now I am wondering about something else: migraines. He has for as long as he's been able to communicate at all indicated pain in his nose/facial mask area. I have repeatedly raised it with the pediatrician but she either blew it off or blamed it on a head cold. When I took him to the ENT for what was supposed to be a swallow study (a story for another day), the ENT also dismissed it, and said his nose looked fine. He keeps telling me "it's hurting," but when I ask him where, he puts his hands over his face. What does that mean?

Well, while trying to research asthma(!) I came across an article in Web MD suggesting that asthma may be linked to migraines. What I was really surprised by was a statement that migraines are also caused by inflammation. I haven't really dug into this, but the article says:

Asthma and migraine share many inflammatory chemicals that are released during an attack, Cady says. “There’s a host of common neurotransmitters that are shared here,” he says, including calcitonin gene-related peptide, histamines and cytokines. “Those are names for inflammatory chemicals that get activated both during asthma and during migraine,” he says.

I don't know anything about Cady except this says he's an MD with some sort of practice specializing in headeaches, but this is really interesting. I had assumed that T's pain was coming from sinuses/allergies, but this article says that this is an assumption many people mistakenly make, and that asthma can in fact be responsible for these kinds of headaches.

Could T be having an asthma headache?? How would I know? He has decreased sensitivity to pain ... might this make him even less communicative than he is already inclined to be about such a problem? Again, how can I know?

I have had such demoralizing experiences with the pediatrician, the ENT, the developmental pediatrician, the ER doctor. Oh,yeah, and the orthopedic surgeon. They either are not interested in the whole picture, too impatient to listen to the whole story, not entirely up to date on everything, or in too big a hurry to impart what I consider to be full information. In short, I have to date found consulting MDs is a good thing to do when your kid is threatened with immediate physical danger, but not terribly helpful toward trying to actually achieve something more. Now that I am paying it all out of pocket, I am having a hard time bring myself to make the appointement with the pulmonologist and/or the allergist.

Prednisone and inflammation and ... vaccines???

Well, my efforts to research whether prednisone really caused some remarkable improvement in my son and if so why have led me down a very strange and twisty path. I can't even remember how I got here, exactly. But I somehow found myself reading a very short article rather forcefully urging that vaccines do not cause autism by authors Jeffrey Gerber and Paul Offit. I guess everyone knows who Dr. Offit is by now, but if you don't, Wikipedia has a bio for him. The short version is he's a prominent pediatrician and vaccine expert at the Children's Hospital of Philadelphia, he's done work for the CDC, and he's quoted OFTEN about the whole vaccine issue. He definitely does NOT think there's any link between vaccines and autism.

Anyhow, this article, Vaccines and Autism: A Tale of Shifting Hypotheses, was fairly unremarkable to me, until I got to this:

Autism is not an immune-mediated disease. Unlike autoimmune
diseases such as multiple sclerosis, there is no
evidence of immune activation or inflammatory lesions
in the CNS of people with autism [38]. In fact, current
data suggest that genetic variation in neuronal circuitry
that affects synaptic development might in part account
for autistic behavior [39]. Thus, speculation that an exaggerated
or inappropriate immune response to vaccination
precipitates autism is at variance with current scientific
data that address the pathogenesis of autism.

This is the part where I started tearing my hair out, because I just got done learning all about how autism is an immune mediated disease with an autoimmune component. Or at least I thought I had.

Frustrated by electronic searching, I had finally checked out what seemed like some "real" medical texts from the Emory University Health Sciences Library. One of them is called Autism: Current Theories and Evidence, and it was published in 2008. It's edited by Dr. Andrew Zimmerman, who as far as I can tell is an extremely well-published, -credentialed, and -respected neurologist at Johns Hopkins and the Kennedy Krieger Institute. This text is part of a series called "Current Clinical Neurology," edited by another impressive sounding individual at the Harvard Medical School. Not exactly sketchy people.

Part IV is called Immunology, Maternal-Fetal Interaction, and Neuroinflammation. There are four different pieces in here on the immune system in autism and neuroinflammation! And on page 329, Dr. Pardo-Villamizar, a colleague of Dr. Zimmerman at Johns Hopkins, writes:

"Several studies showing peripheral immune abnormalities support immune hypotheses; however, until recently there has been no demonstration of immune abnormalities within the [central nervous system]. Recently, our laboratory demonstrated the presence of neuroglial and innate neuroimmune system activation in brain tissue and cerebrospinal fluid of patients with autism ...."

Wow, could there be a more direct conflict here? So I check the dates. The vaccine article by Drs. Gerber and Offit was received by the journal on August 25, 2008. But the research of Dr. Pardo (and Dr. Zimmerman) was published well before then. I found it in a 2005 article called "immunity, neuroglia and neuroinflammation in autism."

So I continue trying to puzzle this out: who's right, who's wrong, can these 2 things be reconciled? I pull footnote 38 from Dr. Offitt's article, the one that supports his statement that "there is no evidence of immune activation or inflammatory lesions in the CNS of people with autism." And discover that Dr. Offitt's support is a 2004 report from the Instute of Health called "Immunization safety review: vaccines and autism." The first thing that went through my mind: really? The most recent citation you can find on this topic is from 2004? And not even a "but see" or "compare"? There's absolutely no suggestion here that maybe somebody else thinks there IS evidence of immune activation in the CNS of people with autism. It's just shocking to me, since I'm staring at it.

I pull the 2004 report. One of the first things that I notice about it and am a little disturbed by is that apparently, this was written by a committee, and it met only once to discuss this topic. At least, it appears that way. When I turned to page v to see who was on the committee I see this: "The following individuals are members of the Immunization Safety Review Committee but were unable to attend the meeting on the topic of this report." That certainly makes it sound like there was only one meeting, doesn't it?

I also notice that they had a large number of additional people review and comment on the report before publication, and interestingly one of those people is Dr. Zimmerman. However, the report expressly states that they didn't necessarily take all the comments from everyone, so it's possible Dr. Zimmerman didn't agree with the report. I can't tell.

But the real important part is what I found when looked at the report itself. There is an entire section on immune dysregulation, beginning on page 128. I found this shocking, because this section is full of citations to study after study after study showing weird things about the immune systems of autistic children. The committee doesn't seem to actually dispute these findings. And here, I will readily admit this material was over my head. But as far as I can tell, what the committee has actually done is this:

1) they critique the various theories and hypotheses that researchers have tried to come up with to explain the obvious immune anomalies that have been observed (without suggesting any of their own); and
2) state that it is irrelevant that autistic children have these immune anomalies, partly because they can't figure out how it could be relevant, and partly because (supposedly) autistic children don't seem to be more prone to allergies.

They start with the sentence: "A large number of studies have suggested that immune dysregulation occurs in autism." The first few weird findings they cite in this report:

* Decreased lymphocyte responsiveness in the lymphocyte blastogenesis assay to PHA, ConA, and Pokeweed mitogen
* significantly reduced natural killer (NK) cell activity (Warren et al., 1987);
* decreased proportion of IFN-gamma- and IL-2 (Th1 cytokine)-staining CD4+ T cells in the serum;
* significant increase in IL-4-(Th2 cytokine)-staining CD4+ T cells

I don't claim to know what all this stuff is, except that it all relates to the immune system. Interestingly, the IFN-gamma jumped out at me, because the medical textbook I picked up on asthma says that asthmatic children had reduced IFN-gamma, but that's not relevant here.

Anyway, there's more, some of which does seem to contradict the above:

*increased levels of plasma IFN-gamma and IL-2 (Th1 cytokines)
* Increased production of serum IL-12, IL-6, tumor necrosis factor-alpha and IFN-gamma, and increased urinary neopterin
* PBMCs (peripheral blood mononuclear cells) from patients with autism, both at baseline and after stimulation with LPS (lipopolysaccharide) and PHA (phytohemagluttinin), secreted significantly more pro-inflammatory cytokines (TNF-alpha, IL-1beta, and IL-6) than those from healthy controls and normal siblings

Basically, they go on to review this bewildering array of findings after which I get the distinct impression that:

1) something is really weird about the immune system in autistic people; and
2) no one really knows why or what it means.

In other words, there is a problem and we are deeply ignorant about it. Their conclusion about these things is: "In summary, although several studies have reported abnormalities of components of the immune systems, they have often had contradictory results, making it difficult to achieve a consensus on any specific immune abnormality that might characterize autism. More fundamentally, it is not clear how these abnormalities might explain the CNS defects in autism or whether they could be secondary to GI or other complications of developmental disability."

But wait, there's more, because then I read:

"A large number of serum autoantibodies have been detected at a higher frequency in children with autism compared to controls. The antigens against which these autoantibodies are directed include a number of CNS antigens, such as myelin basic protein and neuron-axon filament protein, but they also include a whole host of other proteins, such as nerve growth factor, serotonin receptor, alpha-2-adrenergic receptor, tubulin, heat shock protein 90, and chondroitin sulfate."

Now, I've read some of this stuff before, but not in a government report. I am pretty astonished. I never really imagined there was anything like this in here. Especially since Dr. Offitt's report makes it sound as though there is no evidence of anything wrong with autistic individuals' immune systems, although perhaps I misread what he said. But wait,there is just so much more in here, I can't stop quoting it.

The report says: "This suggests that rather than there being a specific antibody response to [central nervous system] antigens, generalized hypergammaglobulinemia resulting from polyclonal B cell activation occurs in autism." I really don't know what they are talking about here, but doesn't it sound a lot like they are suggesting that somebody this "generalized hypergammaglobulinemia" is something to be unconcerned about? Doesn't it seem like it might be relevant to vaccinations? Ok, I'll grant you that maybe it's not. But they are just a little too dismissive for my tastes. They are dismissive of EVERYTHING, and that doesn't sound ... balanced and neutral.

Perhaps my favorite sentence is this one: "Of note in the abovementioned studies, these antibodies were all also found in the serum of healthy controls, albeit at lower levels—i.e., they were not specific to autism, making their pathogenic significance questionable." Well, I don't know about "pathogenic significance," but being just another stupid layperson, I am wondering why they seem to think that it doesn't matter that my son has antibodies at higher levels than everybody else. How can this be irrelevant?

it continued to cite all sorts of evidence of weird things involving the immune system in autistic kids, but they always managed to dismiss them in some way or another. There is an intersting reference to Wakefield, too, btw, but I am trying not to get too off-topic here, so I won't detail that, but you may want to read it for yourself.

I realize that they were focused on addressing one specific question, but in general, it felt a little rude and frankly insensitive to have them lay out all of these horrible sounding findings and then just sort of brush them aside as though they just didn't matter.

Some of their logic is hard for me to follow. Like: "As mentioned, autoantibodies to cerebral antigens, including MBP, have been found at higher titers in children with autism compared to controls. It is important to note, however, that these studies all evaluated serum and not CSF or brain tissue." Okay, so I'm not a doctor, and maybe this would make sense to me if I were, but why would there be autoantibodies to CEREBRAL antigens in your body but yet not in your brain? Am I the only one who thinks this sounds as though they are saying: "Well, sure, they have antibodies in their blood that are designed to attack brain tissue, but hey, no one has ever proven that any of these antibodies actually made it to the brain, so relax. they probably didn't."

And then I hit this: "Some investigators have tried immunotherapies, such as corticosteroids ...." THAT'S prednisone!! They go on to cite anecdotal evidence of both success and failure with this treatment. It is ironic that is what I am REALLY trying to research, but now I don't have time to read the references cited yet. It will have to wait to tomorrow.

I must say I am deeply troubled by this report. Whatever the Truth is about vaccines, there is clearly something up with the immune systems of autistic children, and it has been known for some time. I sort of knew this already, but it was only in a dim and hazy way. Not like this.

This report does not deny that something is up with the immune systems of autistic children. It concludes this section with the anticlimactic:

"By analogy to Rett’s syndrome, similar epigenetic mechanisms may be operating in autism that simultaneously lead to abnormal development in the immune and central nervous systems (Zimmerman, 2000). However, the deviations from expected levels in various in vitro laboratory assays in both these conditions may represent only a secondary effect of the developmental or behavioral abnormalities."

[Note the reference to Zimmerman? I assume that's the same Dr. Zimmerman who edited the book I've checked out, the one full of articles about neuroinflammation and immune dysfunction (among other things).]

So I am left with 2 questions:

1) Why does Dr. Offitt say "Autism is not an immune-mediated disease. Unlike autoimmune diseases such as multiple sclerosis, there is no evidence of immune activation ... in the CNS of people with autism," and why does he think that this report substantiates such a bold assertion? I grant you that the immune problems may go hand in hand with autism without "mediating" autism, but I do not get the impression that anyone understands enough to know for sure whether this is true or not.

2) Why didn't one of my son's doctors tell me ANY of this stuff??

OK, obviously I have more than 2 questions, and those are actually the least important ones. what I really want to know is:

1) what is wrong with my son's immune system?

2) how do I fix it?