William K. ReidSunday, April 3, 2022Amyotrophic Lateral Sclerosis (ALS) remains a terminal disease without an established etiology for the majority of patients. The dominant theory of ALS before 1970’s was the presence of poisons (Wofgram, F. 1973)1. Treatment with plasma exchange to remove poisons was said to have failed (Silani,V. et al1980)2. The exclusion of the theory of poisons in ALS because of the apparent failure of plasma exchange needs reassessment. There is an assumption of a finite body burden of poisons. If, instead, the patient continues to be exposed to poisons after plasma exchange, then the treatment would fail until the source of the poison was removed. There is evidence of chronic fungal infections in ALS patients that secrete neurotoxic mycotoxins. If these neurotoxic mycotoxins are the poisons reported in the old literature, then treatment would require aggressive antifungal therapy along with plasma exchange. There is a third factor complicating therapy. Patients with ALS have significant immune damage and treatment requires repair of the immune system.Introduction :The etiology of ALS has remained elusive. The dominant theory before the 1970’s was the presence of poisons or neurotoxins1. Serum from patients with ALS were toxic to motor neuron cells in culture. Based on this theory multiple institutions treated ALS patients with plasma exchange without apparent improvement2. There is a critical assumption that there is a finite body burden of poison and no further exposures. If, instead, there continues to be exposure to poisons, then treatment would require removal of the source. One source of poisons that could explain all the findings is a chronic fungal infection secreting neurotoxic mycotoxins. The fungal species Fusarium is a likely candidate (Thornton, C.R. 2020, Tortorano, A.M. et al 2014)3,4. Fusarium produces a wide array of mycotoxins of which two have prominent neurotoxicity, trichothecenes or fumonisins. The pathology in humans of trichothecenes mimics the pathology seen in ALS. Fusarium species contaminates water supplies, soil and crops, and are a common cause of onychomycosis, keratitis and sinusitis. Fusarium infections are difficult to treat due to multi-drug resistance. The tools to diagnose Fusarium infections are relatively new and, too often, fungal cultures and tissue hyphae are misdiagnosed as Aspergillus. The most toxic trichothecene produced by Fusarium is T-2 with a pattern of toxicity emblematic of ALS (Dai, C. et al, 2019, Wu, Q. et al 2020)5,6.Fusarium Infections :Fusarium species cause sinusitis, onychomycosis and keratitis in immunocompetent hosts (Thornton, C.R. 2020)3. In the immunocompromised host, Fusarium species cause life-threatening infections, Fusariosis, reported in hematologic cancer patients, HIV, diabetes, liver cirrhosis and especially bone marrow transplant patients. Fusariosis is the second most common invasive mould disease after Aspergillosis with a high mortality rate reaching 75%. Fusarium infections are resistant to almost all the available antifungals. The recommended antifungals are Voraconazole, Amphotericin or combinations. Added to the limited number of antifungals is the impact of mycotoxins that cause immune suppression (Wu, Q. et al 2020)6.

Wednesday, March 3, 2021William ReidAmyotrophic Lateral Sclerosis(ALS) remains a terminal disease without an established etiology for the majority of patients. The dominant theory of ALS before 1970’s was the presence of poisons. One of the primary means of treating patients with a toxic exposure has been plasma exchange, but plasma exchange of ALS patients failed to alter the clinical course. The failure of plasma exchange assumes the patient is no longer exposed to the poison. If the toxic exposure continues after plasma exchange, then plasma exchange alone would fail. The world food supply is contaminated by opportunistic fungi that release mycotoxins. There is mounting evidence of the profound neurologic and immunologic toxicity of the most common mycotoxins. Every ALS patient examined had evidence of a toxic exposure. Treatment with antifungals specific to the most common opportunistic fungi led to improvement in laboratory evidence of a poisoning. The pathology of the common mycotoxins mimics the pathology reported in ALS patients. Along with the profound neurotoxicity of mycotoxins, there is profound immune toxicity. If mycotoxins are involved causing ALS, then the immunotoxicity of mycotoxins could be responsible for the recalcitrance of therapy reported in ALS. New forms of treatment for immune deficits, immune tolerance and immune evasion could remarkably improve the treatment of ALS patients.Introduction :The etiology of ALS has remained elusive. The dominant theory before the 1970’s was the presence of neurotoxins1,2. Serum from patients with ALS were toxic to motor neuron cells in culture. Based on this theory multiple institutions treated ALS patients with plasma exchange without apparent improvement3. The conclusion that plasma exchange was ineffective made a critical assumption that there is a finite body burden of neurotoxin and no further exposures. If, instead exposure to neurotoxins persist after plasma exchange then plasma exchange would be inadequate. The source of toxins whether environmental or endogenous would need to be removed. If neurotoxins were generated by an infectious agent colonizing or infecting patients, then treatment would require control of the infection along with plasma exchange.In every ALS patient studied, there was laboratory evidence of a poisoning4. Patients developed secondary porphyria in a pattern typical of a poisoning. They developed anion-gap positive metabolic acidosis. They all had elevated Kreb cycle intermediates consistent with mitochondrial damage typically seen with toxic exposures. Treatment with anti-fungal agents specific to Fusarium species corrected many of the laboratory findings including the elevated protoporphyrins, the anion-gap positive metabolic acidosis and the elevated Kreb cycle intermediates. This is consistent with the presence of mycotoxin generated by a fungus growing in the patient.The literature on mycotoxins is extensive5-7. Mycotoxins are ubiquitous in the human environment and prominent in the world food supply. Globalization has accentuated the problem. Efforts to prevent or remove fungi and their mycotoxins from food and the environment have been difficult to impossible. Humans are routinely colonized by fungi that populate the skin, gastrointestinal tract, lungs and upper airway8,9. The same fungal species contaminating food are the species colonizing the human airways. Surveys of grain supplies found hundreds of fungal species producing over 700 mycotoxins5. Four fungal genera were routinely reported Aspergillus, Penicillium, Alternaria and Fusarium10,11. Of these fungal genera, Fusarium species were especially problematic12. Studies from otolaryngology reported that fungal colonization of the sinus cavity and upper airway is almost ubiquitous13-16. These studies found the same spectrum of fungal species with Aspergillus and Fusarium listed first and second in frequency. Many of these fungal species are highly resistant to anti-fungal agents especially Fusarium. Fusarium species produce a broad spectrum of mycotoxins with Fumonisins and Trichothecenes predominate12. Both these compounds have significant neurologic toxicity17. The problem of contamination of the human food chain by fungi and their mycotoxins has led to a world-wide industry to control the contamination of food (Romer Labs, Vicom Labs division Waters). Mycotoxin levels vary with environmental factors as well as storage techniques. There has been no successful way to prevent or remove these mycotoxins from food. This has left governmental authorities with few options. They have elected to monitor food supplies, set limits of exposure and discard food that exceed limits.Animals fed hay or grain contaminated with mycotoxins develop serious problems that include neurologic deficits18-20. Horses exposed to hay or grain contaminated with Fumonisins develop Equine Leukoencephalomalacia with paralysis of tongue, incoordination, ataxia, blindness, hind limb paralysis and eventual death with pathology finding severe brain damage.The other dominant mycotoxins from Fusarium are Trichothecenes divided into four groups, A,B,C & D12. The key to their toxicity is the presence of an epoxide ring moiety that generates free radicals setting off Oxidative Stress Reactions. They form covalent bonds to DNA, RNA and proteins. They target the 60S ribosome and peptidyl transferase shutting down protein production. The molecular weight of trichothecenes ranges from 200 to 500 Dalton. They are highly lipophilic able to be absorbed through skin, gut, crossing plasma membranes, including the blood brain barrier. Trichothecenes are known to accumulate in nervous tissue17. In surveys of grain, the trichothecene Deoxynivalenol was the most common with T-2/HT-2 Toxins the fourth most common. Studies of Deoxynivalenol found that it could accumulate in tissues even when levels were below the regulatory limit21.

Amyotrophic Lateral Sclerosis(ALS) remains a terminal disease without an established etiology for the majority of patients. The dominant theory of ALS before 1970’s was the presence of a poison. One of the primary means of treating patients with a toxic exposure has been plasma exchange, but plasma exchange of ALS patients failed to alter the clinical course. The failure of plasma exchange assumes the patient is no longer exposed to the poison. If the exposure to poisons continued, then plasma exchange alone would fail. I found laboratory evidence of a poisoning in every patient with ALS examined. A search for specific poisons found evidence of mycotoxins. Treatment with antifungal agents corrected the laboratory findings. All of the ALS patients had evidence of immune suppression. There is mounting evidence that many mycotoxins cause both neurotoxicity and immune suppression. These mycotoxins may be able to explain the full spectrum of pathology in ALS without a secondary event.

William K. Reid, M.D.Hematology & Oncology 613 Greenwood Rd. Chapel Hill, N.C. 27514 Cellular: (615)405-5162 Email: [email protected], January 25, 2021Hypothesis: Mycotoxins Causing Amyotrophic Lateral SclerosisReviewer’s questions:1. Pattern of Cascade through the Neuroaxis in ALS2. Biomarkers for ALS & for MycotoxinsI. ALS Cascade Upper & Lower Motor Neurons :It is intriguing to relate the available data on neurotoxic mycotoxins with the clinical findings in ALS. ALS is a motor neuron disease with insidious, progressive weakness and muscle wasting. One of the essential clues to the diagnosis of ALS is the involvement of both upper and lower motor neuron disease. The diagnostic strategy presented by Statland et al 20151 defines upper motor neuron deficits with spasticity and hyperreflexia and lower motor neuron disease with muscle wasting, weakness, fasciculations, fibrillations and positive sharp waves. In ALS there is a mixture of both upper and lower motor neuron deficits. The pathology of the neurotoxic mycotoxins, especially the trichothecenes(Dai, C. et al 20192), closely mimics the pathology of ALS with oxidative stress, mitochondrial dysfunction and respiratory chain damage.Intranasal Pathways Bypass of Blood Brain Barrier & CSF :The trichothecenes, T-2 Toxin and Deoxynivalenol, are major contaminants of the world food supply. If the opportunistic fungi responsible for these secondary metabolites develop a niche in the body by colonization or infection, these potent, lipophilic mycotoxins are able to cross barriers, especially the blood brain barrier and accumulate in the brain and spinal cord. Marcesca, M. 20133 reports on of transport of food-associated trichothecenes from the gut to the brain.There is a more intriguing possibility if there is a focus of a fungal infection in the upper airway, especially the upper sinus cavity. There is a growing body of research documenting intranasal delivery of compounds and drugs to the brain and spinal cord. Thorne, R.G. et al 2004 4report on transport of IGF-1 in the nose of rats. Thorne, R.G. et al 20085 report on transfer of interferon-beta in a monkey’s nose to brain. There are extensive studies documenting intranasal absorption of insulin in the objective of replacing injection requirements. Lochhead, J.J. et al 20196 found insulin had neuroprotective effects traveling along the trigeminal nerve. Avgerinos, K.L. et al 20187 found intranasal insulin in 293 patients improved memory in patients with Alzheimer’s or mild cognitive deficits. Intranasal glucagon was effective in adults with type 1 diabetes and insulin-induced hypoglycemia (Rickels, M.R. et al 20168). What these studies discovered are pathways bypassing the blood brain barrier as well as the CSF.Pardridge, W.M. in 20119 and 201210UCLA pointed out misconceptions surrounding drug and compound levels in the CSF, blood and brain. His studies showed that CSF drug levels were the same as systemic blood levels and were not equivalent to brain or spinal cord levels. Over the past 10 years the literature has defined two intranasal pathways that bypass both the CSF and the blood brain barrier.The upper sinus cavity is lined by olfactory mucosa that has direct passage of olfactory nerve endings exposed to the external environment. There is a second lining of respiratory mucosa fed by the ophthalmic and maxillary branches trigeminal nerve. Djupesland, P.G. et al 201411 describes the delivery of drugs from the nasal cavity directly into the brain. Passage is rapid in 5 minutes to 60 minutes passing by convective or bulk flow. Drugs bypass the blood brain barrier and the CSF.The olfactory pathway passes compounds of significant size into the olfactory bulb. The drugs move outside of the neurons with movement by pulsatile flow extracellular pathways. The trigeminal pathways from nasal cavity to brain moves to the midbrain, pons and the lower motor neurons of the spinal cord. The olfactory pathway feeds into the limbic system and forebrain.If there is an infection of the upper nasal cavity involving opportunistic fungi, such as Fusarium species that release lipophilic, neurotoxic mycotoxins, it could poison the brain and spinal cord in an insidious fashion. The pathway from the olfactory bulb to the upper brain would involve the upper motor neurons. The pathway from the trigeminal nerve branches would transport drugs to the brainstem and lower motor neurons (Djupesland, P.G. et al 201411, Lochhead, J.J. et al 201512, Ganger, S. & Schindowski, J. 201813). There are studies of giving chemotherapy intranasally for glioblastoma multiforme (Bruinsmann, F.A. et al 201914, van Woensel, M. et al 201315).Pseudobulbar Affect :Intranasal passage of neurotoxins into the brain and spinal cord would explain the dual injury to upper and lower motor neurons. The olfactory intranasal pathway leads to the olfactory bulb and limbic system. This pathway could help to explain pseudobulbar affect. Thakore, N.J. & Pioro, E.P. 201716 in Cleveland reported on pseudobulbar affect found in 209 out of 735 ALS patients. They found an association with bulbar onset and dysfunction with predominantly upper motor neuron disease. The ALS patients with pseudobulbar affect were younger in age with a shorter duration of disease. They found an association with worse bulbar findings, dysarthria and dysphagia. There was an association with the use of Baclofen, a surrogate for upper motor neuron dysfunction.Misconceptions of Blood Brain Barrier & CSF :Pardridge 20119 and 201210, report on the literature before 2011 with the misconceptions about CSF drug and metabolite levels. The intranasal passage of drugs and metabolites to the brain did not feed into the CSF. This leads to misconceptions when studies assume CSF levels are equivalent to brain and spinal cord levels. In order to get accurate brain levels requires Intracerebral Microdialysis, PET scans or functional MRI (Chefer, V.I. et al 200917, Lasley, S.M. 201918).