Six Months

So, it seems that I am improving again. Six months ago I came back from Argentina, where I spent the boreal winter. I felt better there, as I usually do during summer, in Italy. Feeling better means being able to think, to read, to do calculations, to draw. To exist, in one word. And also to move around a bit, which is not truly relevant for me, though.

I came back to Italy at the end of March (blog post), sure that I would have had other months of improvement ahead of me, given that we were at the beginning of Spring. But it hasn’t been the case, I got worse: For six months I haven’t thought, and I have been living horizontally, in silence. There were days in which it seemed that I was starting to improve (like when I recorded this video), but then it didn’t last. I can’t remember these six months, in my subjective time they sum up to a week or less.

Not sure why it happened: perhaps the 48 hours of the chaotic journey back to Italy damaged me so badly that it took half a year for me to regain the status quo ante, or maybe the strange flu I got in March, while in Argentina, made the disease worse. In the life of an ordinary person, this would be a rather exceptional episode, for me it is the rule: the improvements are the rare exception. I have lived like that since I was 20.

And now, because I usually get worse at the end of September, I know that I am about to start my descend to Hell again. And this time I can’t move to the austral hemisphere, because of the pandemic. So what am I supposed to do in the few days of life I have left? I’ll do what I have always wanted to do: applied maths and drawing, with only very short term goals. Something that I can finish.

I share these private vicissitudes only because I think that it is important to let the world know about this struggle. It seems unlikely that I can discover the reason why this curse has stricken my life, but I will continue studying this phenomenon: most of what I study, when I can, is about new tools to apply to my own biology.

The indiscreete rotation

The world must be wonderful, beyond the muffled atmosphere of these rooms and the obstinate curtain of encephalopathy; now that Autumn is still a harmless chrysalis, an apparently unlikely threat, while the industriousness of men swarms again, in search of untouched paths.

The Autumn of intellectual and material adventures, of encounters and discoveries, remains an unfulfilled promise, which I nevertheless do not give up on cultivating. Because I don’t know if Ulysses kissed his stony Ithaca during this season, but I like to think so.

I am perpetually mocked by the indiscreet rotation of the wall clock, which turns on the spot; while Rilke’s panther remains trapped in my chest.

Is it that bad?

Is it that bad?

When I got sick, about 20 years ago, for the first time I started thinking about diseases and loss of health. And I remember coming to the conclusion of how fortunate I was, from a physical standpoint. Not of how fortunate I had been in the past (that was obvious), when I could conquer mountains, running on rocks with my 15 Kg bike on the shoulders; no, of how fortunate I was in that very moment, while confined at home, mostly lying horizontally. I was fortunate, I could still move my hands, I had still all my body, even if I couldn’t use it in the outside world, even if most of the usual activities of a 20 years old man were far beyond reaching, I realized how fortunate I was. And after 20 years I still say that, as for the physical functioning, I am a very lucky man. There are even some years, during the core of the summer, in which I can run for some minutes in the sun. I am blessed.

I am aware that this might offend some patients, but I think that those who have ME/CFS in the vast majority of cases are fortunate too, from a physical standpoint. Yes, it is annoying to need help from others for so many things, but with assistance and some arrangements, you can go on with a productive life… unless you have cognitive impairment.

Actually, I never felt fortunate concerning my cognitive functioning. That has been a true tragedy, I have lost my entire life because of the cognitive damage, by any means because of the limitations of my body. I would have had a meaningful life (according to any standard) even with physical limitations way worse than mine if I had had a functioning brain. But I lost it when I was 20 before I could get the best from it and that is the only real tragedy.

As an example of what I am saying, consider a person like Stephen Hawking: he has been a prolific scientist, he had a stellar career (literally), he shaped our culture with his books for the general public, he was a father of three, and so forth. And yet for most of his life, while he was doing all these things, his physical functioning was way worse than the one of the average ME/CFS patient (worse even of a very severe patient, probably). For many years he could use only the muscles of the head. That’s it. Think about that. Was he missing or invisible? Definitely not!

Was he a disabled man? Yes, technically speaking he was, but in fact, he has never really been disabled, if we judge from his accomplishments. He once said that the disease somehow even helped him in his work, because he could concentrate better on his quantum-relativistic equations¹.

So what I am saying is that if we consider the physical functioning in ME/CFS, it is a negligible problem in most of the cases. The only thing that matters is the impairment in cognition (in the cases in which it is present), especially if it starts at a young age (consider that after you reach your thirties there is very little chance that your brain will give a significant contribution to humanity, even if you are perfectly healthy, so it is not a big loss if you get sick after that age). That is disastrous and there is no wheelchair you can use for it. For all the other symptoms you can find a way to adjust, just as Hawking did in a far worse situation.

This might be one of the reasons for the bad reputation of ME/CFS: there isn’t awareness about cognitive issues, no one talk about them (and in some cases, they are in fact not present at all). But I am pretty sure that the real source of disability in these patients, the lack of productivity, is due to their cognitive problems (when present). Also because in a world like ours, you can work even without using most of your muscles. It is not impossible, I would say it is the rule for a big chunk of the population.

The following one is an interview with Norwegian neurologist Kristian Sommerfelt, in which he points out some analogous considerations. He has done some research on ME/CFS with the group of Fluge and Mella, including the well-known study on pyruvate dehydrogenase. From the subtitles of the video (minute 3:38):

“This [the cognitive problem] is a very typical ME symptom and some of what I believe causes the main limitation. I don’t think the main limitation is that they’re becoming fatigued and exhausted by moving around, walking, running, or having to sit still. If it were just that, I think many ME-patients could have had a much better life. But the problem is that just actively using the mind leads to problems with exactly that, using the mind. It comes to a stop, or slow down, depending on how ill they are.”


¹ It seems that Stephen Hawking had a very unusual presentation of Amyotrophic Lateral Sclerosis (ALS): one half of those with this disease die within 30 months from the first symptom; moreover one out of two ALS patients has a form of cognitive impairment which in some cases can be diagnosed as frontotemporal dementia [R]. So, Stephen Hawking was somehow lucky, in his tragedy, and he doesn’t represent the average ALS patient. I mentioned his case as an example of a person with very severe physical impairment and no apparent cognitive decline, not as an example of the average ALS patient. 

About me

About me

The following video is meant to be a presentation of both the blog and of myself. As I started improving again, some days ago, I decided to record this monologue, so that there could be a video memory of my struggle.

This winter I have spent almost three months in South America, to see if I would have improved during the austral summer, as I usually improve during the Italian summer; and in fact, I did improve. When I came back to Italy (in March) I had a relapse, though. For the last three months, I have been mostly horizontal, without reading or thinking for most of the time.

Now I am climbing the mountain again: I started my rehabilitation reading novels some days ago, then I switched to simple calculations and now I have written my first small code since March. And when I will reach the cognitive level I had about 20 years ago just before I got sick, I will lose everything for months (or years) and I will have to wait without thinking much (despite my best efforts) until I can start all over again…

The myth of Sisyphus has been shaped after me.

 

 

My saviour

One of my short-lived summer improvements (2013). During all these years, as soon as I started feeling better, I opened my books, even before taking a shower and having my hair cut. Happy as a child for most of the time, but also profoundly saddened for the time lost, especially at the beginning of the improvement, when I could realize how much time had passed from the previous positive phase.

97284908_10220774536729711_4708150532923981824_n

Each time I had to start exactly from where I had left many months or even years before (the longest gap has been 5 years without studying). I had to do a cognitive rehabilitation each time, learn again how to read properly, how to do math, how to discipline my thoughts, how to code. It is a hard process each time. And then, a few weeks after, when I recovered enough to function mentally, I relapsed again.

I am pretty sure that only this complete, obsessive devotion to studying has saved me from very bad cognitive disability.

Before getting sick, coding and math had taught me how to think. Then, when I became ill, each equation I wrote, each drawing and code, all those efforts made to bring my soul back from wherever it was, they kept me alive for all these years.

My first time with LaTeX

Each mathematical formula I have used in my blog till now was an image: I wrote them in a Word document using the equation editor by Microsoft (that I like very much), then I captured the screen and saved it as an image and then I uploaded them in my blog.

In the past, I tried to find a way to write them as text, without succeeding. But in fact, it is possible, using the LaTeX syntax and a few HTML commands.

These are the first “true” mathematical formulae present in this blog. I will use this page to test the LaTeX syntax for mathematical expressions (a handbook is available here).

\int_{A_1}\int_{A_2}\frac{\partial \Psi(x,y)}{\partial x}dxdy

i\hbar\frac{\partial}{\partial t}\left|\Psi(t)\right>=H\left|\Psi(t)\right>

A symbol within the paragraph: \pi. A inequality within the paragraph: x_i>0. This is an example of an expression with a pedix that has a pedix: f_{X_1}.

The time machine

I am aware that these are just messages floating in the silence, stored somewhere in the planet as binary numbers. I am writing to myself, mainly, from my remote hiding place.

I have travelled through ages, without really being part of them. All alone with my problem. As a patient with a rare disease that doesn’t even have a proper description, I do not belong to humankind.

But humans have paradoxical behaviours, they care more about a man who lived five thousand years ago in the north of Italy, trapped in the ice of our highest mountains, than of clochards that live right now in pain and loneliness in their community. So it might be that generations from now, someone will find these notes, an archaeologist who will try to build my story, from fragments of what I left behind: drawings and calculations. Mathematics is a universal language, after all, and to some extent, even art is universal; not always but often, good art is forever.

If I fail my mission, history will never record my existence. But it might be that at some point in the future someone will find these notes frozen in the ice of a planet long forgotten by humans themselves, as we now have forgotten Africa, the place we all come from.

 

Why I study my own disease

Why I study my own disease

A lot of patients have asked me why I use my little energies to study my disease, instead of just waiting for science to conquer it.

There are many reasons, the first one being that I am desperate because of the cognitive disability that is worse than death. I am not concerned about the physical limitations, at all, even though I have been mostly housebound for the last 20 years. Another reason is that I like computational biology, and I started studying engineering before getting sick with the idea of switching to bioengineering after graduating. So, this is my job.

The other point is that even though I fit the criteria for ME/CFS, I have a rare disease, granted that ME/CFS is not a rare disease: it has a prevalence of 0.4% according to some studies, so it is relatively common. Then why am I a rare patient? Let’s do some calculations: since the median age at onset is 36.6 years with a standard deviation of 12.3 years, the proportion of males is 19% and the proportion of those who are housebound for most of their disease is 25% (R), the probability for a ME/CFS patient of having my same characteristics is (assuming that these are all independent random variables) given by p=0.0075. So, less than 1 out of 100 ME/CFS patients has my type of illness. If we consider also that pain or aching in muscles is present in 59% of patients and it is mostly absent in my case, the above-mentioned probability is even lower: p=0.0031. Which means that only 3 ME/CFS patients out of 1’000 have my illness.

Taken all these data together, the prevalence of my disease in the general population becomes 1/100’000, which means that I have a rare disease, according to the European definition (where a disease is defined rare if it has a prevalence ≤1/2’000) [R]. In the US a disease is defined rare only if it has a prevalence ≤1/200’000, though [R].

And besides that, it is pretty obvious that I am a unique case. I have never found a patient like me, so far. It can also be noted that in Italy, given a population of 60 million inhabitants, those who have my condition are only 600. This might be the reason why I haven’t met them, yet.

This means that I am probably the only one who is studying my disease, on the planet! This is why I’m doing what I’m doing.

91569815_10220268929849855_9111778109215997952_o

Above, my personal book of immunology, built page by page, paper by paper. I have three other books about this discipline. One of them was a gift from a neurologist that perhaps thought that gift was the only thing she could do to save me. Another one is a very sophisticated text on cutting edge immunology. But this one is the best one because I have selected and read each one of its pages. It is by no means a complete book, it is mainly focused on B cells and B cell autoimmunity, but it has been very useful.

I have built several other books like this, on computational methods in immunology, on metabolism, on neurosciences, on microbiology, and on some diseases: Lyme, ME/CFS, mast cell activation, POTS…

I have learned a great deal, even though outside academia. But I had no choice, I have been too sick and too slow to study at university: I had only a few weeks in which I could study, and then months or years in which I had to wait. This has been my routine. Moreover, given the lack of energy and time, I had to study only what was truly important for my health. Because my goal was to cure myself and save me from a lifetime of cognitive disability.

Testing hypotheses

Testing hypotheses

Introduction

My ME/CFS improves during summer, in the period of the year that goes from May/June to the end of September. I don’t know why. I have several hypotheses. One possible reason for the improvement in summer is an interaction between the light from the Sun and some parts of my physiology, the immune system for instance. We know that ME/CFS tends to have an oscillating course in most of the patients (Chu L. et al. 2019), but the presence of a seasonal pattern in this patient population has not been investigated so far, to my knowledge. And yet, if you ask directly to patients, many of them say that they feel better in summer. Unfortunately, we don’t have scientific data on that, this is an area worth investigating with some carefully done survey.

Seasonal variation of the immune system

The immune system has a high degree of variation for several reasons (Brodin P et Davis MM 2017). In particular, there are studies about the seasonal fluctuations in the expression of some crucial genes of the immune response (Dopico XC et al. 2014).

How does this regulation happen? Different mechanisms are possible, some of them might be related to changes in the light we receive from the Sun as the Earth rotates around it. We know that the length of the day has an effect on innate immunity: the more the hours of light, the lower the power of the innate immune system (Pierre K. et al. 2016). We also know that ultraviolet radiation, particularly UVB, is an agonist for the aryl hydrocarbon receptor (AhR) (Navid F. et al. 2013). This receptor seems to reduce the expression of the major histocompatibility complex II (MHC II) in dendritic cells (DCs), thus reducing their antigen-presenting activity (Rothhammer V. et Quintana F.J. 2019). UVB might be able to reach dendritic cells when they are circulating near the skin, during summer, thus inhibiting their antigen-presenting activity. Infrared radiation, on the other hand, seems to have an effect on energy metabolism: in Fall we lose a significant amount of infrared radiation in a wavelength range (0.7-1.0 nm) that is known to have an effect on mitochondrial activity (Nguyen L.M. et al. 2013) and it might perhaps have an indirect effect on immunity too.

As further proof of seasonal fluctuation in immunity, some immunological diseases have this kind of seasonality: Rheumatoid arthritis (Nagamine R. et al. 2014) and Rheumatic fever (Coelho Mota C.C. et al. 2010) are two examples. Moreover, the prevalence of Multiple Sclerosis is directly proportional to the latitude (Simpson S. et al. 2011). We also know that there is seasonal fluctuation in serum autoantibodies (Luong T.H. et al. 2001).

Of course, sunlight might be just one of the variables into play. The other aspect I am considering is the seasonal distribution of some common pathogens. Streptococcus, Enteroviruses and Fungi of the genus Penicillium are known to have a seasonal distribution with a peak in Fall and/or Winter (Ana S.G. et al. 2006), (Salort-Pons M et al. 2018), (Coelho Mota C.C. et al. 2010). Common influenza has this pattern too. Rheumatic fever, a disease due to an abnormal immune response to Streptococcus, has its flares in Fall because Streptococcus is more common in that period of the year (Coelho Mota C.C. et al. 2010). Even the composition of the gut microbiota has a seasonal pattern (Koliada A. et al. 2020). I am currently investigating my immunosignature, measured with an array of 150.000 random peptides, to see if I can find some relevant pathogen in my case. You can find this study here.

An experiment

I moved from Rome (Italy) to Rosario (Argentina) at the beginning of January. I was very sick and I steadily improved after about 40 days. I became a less severe ME/CFS patients and I could work several hours a day and care for myself, granted that I did not exceed with aerobic exercise. At the end of March, I started deteriorating as it usually happens at the end of September, when I am in Rome. In order to study this phenomenon, I have built a complete model of solar radiation at sea level, which considers the inclination of sunrays in function of the latitude and of the day of the year. It takes into account the effect of the atmosphere (both diffusion and absorption) and the eccentricity of the orbit (Maccallini P. 2019). If you look at the figure below (a byproduct of my mathematical model) you can see that when I started deteriorating in Rosario, the power of sunrays at noon in that city was still as high as it is in Rome during the summer solstice (this is due to the fact that the Earth is closer to the Sun in this period and to the fact that Rosario is closer to the Equator than Rome is).

Rome_vs_Rosario

So I have to discard the original idea that the power within the infrared range, or the ultraviolet radiation, or the visible one is responsible for my improvement in summer. If I still have to consider that sunlight has something to do with my improvement, I must conclude that it is the length of the day the relevant parameter: I may need more than 12 hours of light to feel better. Why? Because the longer the day, the lower the strength of the innate immunity. This is now my working hypothesis and I will start from the following mathematical model to pursue this research: (Pierre K. et al. 2016).

I will also use full-spectrum lamps early in the morning and in the evening to reproduce a 15 hours day, so to dampen down my innate immune system in a safe, drug-free way. I have to reproduce a day of 15 hours and see what happens. In the figure below the hours of the day at dawn and at dusk and the length of the day for Rome, for each day of the year (this is also a plot from my model).

ore di luce

What follows is the script I have coded in order to plot the first figure of this post. More details on this model of solar radiation are here: (Maccallini P. 2019). As a further note, I would like to acknowledge that I started pursuing this avenue in the summer of 2009: I was building the mathematical model of solar radiation (see figure below, made in 2009) but as the summer finished, I turned into a statue and I had to stop working on it. When I improved, about a year later I started working on the systematic analysis of the mechanical equilibrium of planar structures (it is a chapter of this book). I am proud of that analysis, but it has not been very useful for my health…

trigonometria sferica 2

% file name = sun emissive power sea level Rosario vs Roma
% date of creation = 07/11/2019
% sun emissive power per unit area, per unit wavelength at sea level
clear all
% three parameters of the orbit
A = 6.69*( 10^(-9) ); % 1/km
B = 1.12*( 10^(-10) ); % 1/km
delta = pi*313/730;
% the two parameters of Plunk's law
C_1 = 3.7415*( 10^(-16) ); % W*m^2
C_2 = 1.4388*( 10^(-2) ); % mK
% Stefan-Boltzmann parameter ( W/( (m^2)*(K^4) ) )
SB = 5.670*( 10^(-8) );
% radius of the photosphere (m)
R_S = 696*(10^6); % m
% temperature of the photosphere (K)
T_S = 5875;
% conversion of units of measurments
N = 20; % dots for the equator
R = 3.8; % radius of the orbit
ro_E = 1.3; % radius of the earth
lambda_Rosario = -32*pi/180; % latitude of Rosario (radiants)
lambda_Roma = 41*pi/180; % latitude of Rome (radiants)
delta = 23.45*pi/180; % tilt angle
% the array of theta
theta(1) = 0; % winter solstice (21/22 December)
i_ws = 1;
day = 2*pi/365;
days = [1:1:366];
for i = 2:366
theta(i) = theta(i-1) + day;
if ( abs( theta(i) - (pi/2) ) <= day )
i_se = i; % spring equinox (20 March)
endif
if ( abs( theta(i) - pi ) <= day )
i_ss = i; % summer solstice (20/21 June)
endif
if ( abs( theta(i) - (3*pi/2) ) <= day )
i_ae = i; % autumn equinox (22/23 September)
endif
endfor
% the array of the radius (m)
for i=1:1:366
o_omega (i) = (10^3)/[ A + ( B*sin(theta(i) + delta ) ) ]; % m
endfor
% the array of the wavelength in micron
N = 471;
L(1) = 0.3;
L(N) = 5.0;
delta_L = ( L(N) - L(1) )/(N-1);
for j = 2:N-1
L (j) = L(j-1) + delta_L;
endfor
% the array of beta*L
load beta_int.mat S
% the array of L in metres
L_m = L*( 10^(-6) );
% angle psi
psi(1) = 0;
minute = pi/(12*60);
for i = 2:(24*60)+1
psi(i) = psi(i-1) + minute;
endfor
% -----------------------------------------------------------------------------
% Rosario
lambda = lambda_Rosario
% angle between n and r at noon in Rosario
for i= [i_ws, i_ae, i_ss, i_se]
for j=1:(24*60) + 1
% scalar product between n and r
scalar_p(j) = [cos(lambda)*sin(psi(j))*cos(delta) + sin(lambda)*sin(delta)]*( -cos(theta(i)) )+ [(-1)*cos(lambda)*cos(psi(j))]*( -sin(theta(i)) );
endfor
% value of psi at noon
for j=1:(24*60) + 1
if ( ( scalar_p(j) ) == ( max( scalar_p ) ) )
j_noon = j;
psi_noon (i) = psi(j);
endif
endfor
% angle between n and r at noon
cos_gamma (i) = scalar_p(j_noon);
endfor
% the array of the emissive power (W/(m^2)*micron) in Rosario
for i = i_se:i_se
for j=1:N
num = C_1*( (R_S)^2 );
den = ( (L_m(j)^5)*( (e^(C_2/( L_m(j)*T_S ))) - 1)*( (o_omega(i))^2 ) )*10^6;
power(j,i) = ( num/den )*( e^(-S(j)/cos_gamma (i)) );
endfor
% plotting
plot (L (1:N), power(1:N,i), '-r', "linewidth", 2)
xlabel('wavelenght ({\mu})');
ylabel('W/m^{2}{\mu}');
axis ([0.3,5,0,1500])
grid on
endfor
hold on
% -----------------------------------------------------------------------------
% Rome
lambda = lambda_Roma
% angle between n and r at noon in Rosario
for i= [i_ws, i_ae, i_ss, i_se]
for j=1:(24*60) + 1
% scalar product between n and r
scalar_p(j) = [cos(lambda)*sin(psi(j))*cos(delta) + sin(lambda)*sin(delta)]*( -cos(theta(i)) )+ [(-1)*cos(lambda)*cos(psi(j))]*( -sin(theta(i)) );
endfor
% value of psi at noon
for j=1:(24*60) + 1
if ( ( scalar_p(j) ) == ( max( scalar_p ) ) )
j_noon = j;
psi_noon (i) = psi(j);
endif
endfor
% angle between n and r at noon
cos_gamma (i) = scalar_p(j_noon);
endfor
% the array of the emissive power (W/(m^2)*micron) in Rosario
for i = [i_ae, i_ss]
for j=1:N
num = C_1*( (R_S)^2 );
den = ( (L_m(j)^5)*( (e^(C_2/( L_m(j)*T_S ))) - 1)*( (o_omega(i))^2 ) )*10^6;
power(j,i) = ( num/den )*( e^(-S(j)/cos_gamma (i)) );
endfor
endfor
hold on
plot (L (1:N), power(1:N,i_ae), '-k', "linewidth", 2)
plot (L (1:N), power(1:N,i_ss), '--k', "linewidth", 2)
legend ('spring equinox in Rosario', 'autumn equinox in Rome', 'summer solstice in Rome', "location",'NORTHEAST')
hold on
plot ([0.4,0.4], [0,1500], '--k', "linewidth", 1)
plot ([0.7,0.7], [0,1500], '--k', "linewidth", 1)