Cytokines IN FIBROMYALGIA SYNDROME

1. Dr. Ghizal Fatima
Assistant Professor,
Departments of Biotechnology, Era’s
Lucknow
Medical College and Hospital, Lucknow
DECIPHERING THE ROLE OF INFLAMMATORY
CYTOKINES AND THEIR CORRELATION WITH CLINICAL
MANIFESTATIONS IN WOMEN WITH FIBROMYALGIA
SYNDROME

2. What is this thing that lurks inside?
It steals my body and my mind,
It leaves me with a fear so strong
I think and wonder, what is wrong?
I cannot walk the way I should,
I cannot run, I wish I could.
What else will it steal in the morning light?
I cannot let it, I must fight.
How can I fight what I cannot see
This monstrous thing inside of me?

3. Introduction
• Fibromyalgia Syndrome (FMS) is a chronic
musculoskeletal syndrome characterized by
diffuse pain, stiffness, and tenderness of specific
anatomic sites which are called tender points.
• FMS has been associated with a wide spectrum of
symptoms such as allodynia, debilitating fatigue,
joint stiffness, sleep disturbances, headache,
irritable bowel syndrome, numbness or tingling of
the extremities, restless legs syndrome, dizziness,
cognitive and memory problems, mood
disturbance such as depression and anxiety.

4. This condition affects mainly women, with a
female-to-male ratio of 9:1, and its
estimated prevalence in various populations
varies between 2% - 5%.
Epidemiology of FMS

5. • There are several clinical conditions integrated with
increased inflammatory cytokines, but novel data
suggest a relationship between inflammatory cytokines
and pain perception.
• Furthermore, there is scant information available in
scientific literature about inflammatory cytokines and its
correlation with clinical symptoms in FMS.
• Therefore, in the present study we examined the
inflammatory cytokines in women with Fibromyalgia
Syndrome (FMS) and also evaluated its correlation with
the severity of its symptoms.

6. Objectives
• Assessment of the Inflammatory cytokines by
measuring the levels of tumor necrosis factor alpha
(TNF-α), interleukin 8 (IL-8), IL-1β, IL-1α, IL-2, IL-4, IL-
6, IL-10 and IL-18 in serum of female patients satisfying
American College of Rheumatology (ACR) criteria for
FMS and control group.
• To evaluate its relationship with FIQR and Inflammatory
cytokines in women with FMS and control group.
• .

7. Materials and Method
• Inflammatory cytokines were determined by measuring the levels of
tumor necrosis factor alpha (TNF-α), interleukin 8 (IL-8), IL-1β, IL-
1α, IL-2, IL-4, IL-6, IL-10 and IL-18 in serum in 100 female
patients satisfying American College of Rheumatology (ACR)
criteria for FMS and 100 healthy females without FMS.
• Clinical assessment was done by following questionnaires
1- General Assessment Questionnaire (self designed)
2- Fibromyalgia impact Questionnaire Revised (Bennett et al, 2009)

8. Inclusion and exclusion criteria
Inclusion Exclusion
Patients who fulfilled the criteria
developed by the American
College of Rheumatology (1990)
were included in the study.
Smokers and those using any oral
contraceptives were excluded from the
study as these factors can influence the
oxidative stress parameters.
Informed consent for inclusion in
the study were taken from all the
subjects.
Moreover, subjects with known co-morbid
conditions like diabetes mellitus, psychiatric
and those suffering from Rheumatoid
arthritis or other inflammatory joint disease
were also excluded from the study.

9. Diagnosis of patients: (FMS)
Diagnosis is based on the standardized criteria developed by the
American College of Rheumatology (1990). The criteria is-
1)-Widespread musculoskeletal pain for at least 3 months.
2)-Tenderness is found in at least 11 out of 18 anatomical sites in
making a fibromyalgia diagnosis with the application of 4 kg
pressure by palpation through first three fingers.

11. Statistical analysis
• Statistical analysis was done using SPSS statistical software
(16.0 versions).
• Quantitative variables of FMS patients and controls were
presented as the mean ± standard deviation, and are compared
by independent t-test.
• Pearson correlation was done to find the pattern of associations
between the groups.
• A value of p<0.05 was considered statistically significant and
p<0.01 is considered highly significant.
• .

12. Clinical and Biochemical Characteristics
among Study and Control groups
Parameters FMS=100
[mean ± SD]
Controls=100
[mean ± SD]
P-value
Age (years) 36.7±9.8 34.8±10.5 N.S
ESR 27.2±9.7 24.9±8.2 N.S
FIQR 87.2±11.4 35.0±8.3 <0.05
Tender Points 16.6±1.9 11.3±2.2 <0.05

13. Clinical characteristics of FMS patients and control group
Variables FMS (n=100)
Mean
Control (n=100)
Mean
p-value
Muscles twitching
Yes 92 9
<0.05No 8 91
Disequilibrium in Climbing stairs
Yes 74 6
<0.05No 26 94
Frequent awakening
Yes 72 2
<0.05No 28 98
Sleep status
Sound sleep (Yes) 12 92
<0.05Disturbed sleep (No) 88 8

14. Clinical characteristics: cont.
Morning Stiffness
Yes 90 4 <0.05
No 10 96
Morning fatigue
Yes 92 4 <0.05
No 8 96
Headache
Yes 82 12 <0.05
No 18 88
Lack of energy
Yes 94 14 <0.05
No 6 86

15. Cytokines among Study and Control groups
Parameters Study (n=100)
(Mean ± SD)
Control (n=100)
(Mean ± SD)
P-Value
TNF-alpha
38.31±2.37 22.4±3.35
p<0.001
IL-6
42.90±3.45 19.02±4.26
p<0.001
IL-1β
44.49±3.06 20.1±3. 49
p<0.001

16. Inflammatory cytokines among Study and
Control groups
Parameters FMS patients
n=100 Mean ±SD
Control n=100
Mean ±SD
p-value
IL-8 41.0±5.1 17.3±3.6 <0.05
IL-10 28.2±5.7 12.7±3.8 <0.05
IL-18 39.0±5.1 11.3±3.6 <0.05
IL-2 48.2±4.7 28.7±2.1 <0.05
IL-4 46.4±4.2 19.1±3.3 <0.05

17. Pearson correlation analysis in between TNF-α , IL-
1β, IL-6 and TPC and FIQR.
Parameters Groups TPC FIQR
r r
TNF-alpha FMS patients -0.043 0.513*
Control 0.065 0.129
IL-1β
FMS patients 0.082 0.434*
Control 0.090 0.115
IL-6 FMS patients -0.063 0.439*
Control 0.045 0.139

18. Parameters Groups TPC FIQR
r r
IL-8
FMS patients -0.093 .064
Controls .114 -.179
IL-10
FMS patients -0.138 -.116
Controls -.133 .130
IL-18
FMS patients 0.058 -.156
Controls -.101 .064
Pearson correlation analysis in between IL-8 , IL-10,
IL-18 and TPC and FIQR.

19. Conclusion
• The higher levels of inflammatory cytokines found in
FMS patients suggest the presence of
an inflammatory response system and highlight a
parallel between the clinical symptoms and
biochemical data.
• Therefore, the hypothesis that cytokines may play a
role in the clinical features of FMS is hence proved.

20. • The positive correlation between the levels of
cytokines and symptoms of FMS strengthens the
hypothesis of the involvement
of inflammatory mechanisms in the worsening of the
symptoms of this syndrome.
• The present results indicate that women with FMS are
exposed to increased cytokines levels and this
escalated inflammatory cytokines may play a role in
the etiopathogenesis of the disease.

21. • Non-pharmacological interventions in FM
patients include habitual exercise programs
which improve physical function and quality of
life of patients and may even reduce pain.
• However the mechanisms through which
exercise benefits FM symptoms needs to be
elucidated.

22. While focusing our attention on the
inflammatory hypothesis of FM, as well as on the
beneficial effects of habitual exercise as a co-
therapy for FM patients.
• In this context, the latest developments in
research on anti-inflammatory effects of exercise
are reviewed and discussed.
• To find out what is known about the connection
between benefits of exercise for FM and anti-
inflammatory effects of exercise, we carried out a
PubMed search using the term "fibromyalgia"
and "exercise" together with "inflammation", and
no more than ten published articles were found
(six of them reviews).

23. • In the second part of the article we present a
pilot investigation on a group of 14 female FM
patients.
• They took part in a pool-aquatic program in
warm water over a period of fourth months
(three weekly 60-min sessions and light Yoga
exercise).
• Circulating inflammatory (IL-1beta, IL-2,
IFNgamma, TNFalpha, IL-8, IL-6, IL-4, IL-10 and
CRP) and neuroendocrine (NA and cortisol)
markers were determined.

24. • FM patients showed higher circulating levels of IL-
8,2,4,6,10 and CRP as well as cortisol than age-
matched healthy control women.
• After the exercise program, a significant decrease in
IL-8,2,4,6,10, and CRP were found, in parallel with a
decrease in circulating concentrations of cortisol.
• The results confirm an elevated "inflammatory
status" in the FM syndrome and strengthen the
hypothesis that the benefits of exercise in FM
patients are mediated, at least in part, by its anti-
inflammatory effects.

25. Discussion
• Ranzolin A, 2016, J. Cytokines. Observed higher levels of IL-
10,2,6,18 (an anti-inflammatory cytokine) in patients with
FMS.
• Emberg et al,J. Mediators Inflamm. 2018. The elevated plasma
levels of several cytokines supports the hypothesis that
chronic systemic inflammation may underlie the
pathophysiology of FMS .
• Pernambuco et al, Clin. & Exp. Rheu. 2017. The
positive correlation between the levels of IL-18 and of
other cytokines strengthens the hypothesis of the
involvement of inflammatory mechanisms in the development
of this syndrome.

26. Study on Disturbances of Circadian Rhythm in patients with
F FMS: Published in
1-Ghizal Fatima* Siddharth Kumar Das Abbas Ali Mahdi Some oxidative and
antioxidative parameters and their relationship with clinical symptoms in women with
Fibromyalgia Syndrome. Int J Rheum Dis. 2018; 20:39-45.(2.42)
2-Ghizal Fatima* Siddharth Kumar Das Abbas Ali Mahdi Nar Singh Verma Faizan Haider
Khan,Baby Anjum. Evaluating relationship in cytokines level and Fibromyalgia Impact
Questionnaire Revised with Body Mass Index in women with Fibromyalgia Syndrome. J
Back Musculoskelet Rehabil 2015
3-G Fatima, F Mahdi. Deciphering the role of oxidative and antioxidative parameters and
toxic metal ion content in women with Fibromyalgia Syndrome Free Radical Biology
and Medicine, 2018
4-Ghizal fatima, S.K. Das, A.A. Mahdi, N.S. Verma. Circadian rhythm of serum Cortisol in
Female Patients with Fibromyalgia Syndrome. Indian Journal of Clinical Biochemistry.
2017
5-Ghizal Fatima, Siddharth Kumar Das, Nar Singh Verma, Faizan Haider Khan, Abbas Ali
Mahdi , Baby Anjum. Circadian variations of 5-hydroxytryptamine in female with
fibromyalgia syndrome: a case control study. Sleep and Biological Rhythm 2013
6-Ghizal Fatima, Abbas Ali Mahdi , Siddharth Kumar Das, Baby Anjum, Nar Singh Verma
, Puneet Kumar and Ragini Shrivastava. Lack of circadian pattern of serum TNF-alpha
and IL-6 in patients with Fibromyalgia Syndrome. Ind J Clin Biochem

27. Sampling design
First sample
collected
at 6 a.m.
Second sample
collected
At 12 noon.
Third sample
collected
At 6 p.m.
Fourth sample
collected at
12 mid-night.
Blood samples were collected at the
4 designated times of the day.
However, 6 or 7 control
Samples were collected at
11-11:30 pm and at 6 -6:30 am.
The mid-night samples of patients and
Controls were drawn
And kept for 30 min. for serum
Separation and then stored at
2-8 C. for 6 hr. and centrifuged
In the morning and stored at
-40 C.

28. The observations of abnormalities in melatonin and cortisol which are
highly regulated by circadian pacemaker raise the possibility that there is
an abnormality of circadian rhythm in FMS patients.
Our results suggests that circadian rhythm of symptoms in FMS patients
varies substantially with the time of the day.
This study resulted in better understanding of the circadian rhythm in
FMS patients. The Chronobiological theory has important implications
with regard to the treatment or management of patients with FMS.

29. • Moreover, the diurnal variation of symptoms
suggests that the optimal midday time for the
least pain and fatigue provides opportunities to
promote and to monitor the response to
treatment programmes and has important
implications in the assessment of the patients.
• Therefore, timing may be crucial in treating
disease like FMS and this has important
implications for scheduling activities of daily
living and possibly for timing the
administration of medications.

30. Decreased
Melatonin Level
Maximum Stress
Elevated Cortisol Level
Impaired sleep
Maximum
Numbness
Worst Stiffness
Fatigue
Least stiffness,
Anxiety and
Pain
Worst
Fibromyalgia Syndrome : Circadian
Rhythm of Symptoms
Feel good time
Day time
Sleepiness
Immense Fatigue
minimally Alert
Difficulty in
Concentration.Dizziness
12
Mid night
12
Noon
6 PM
6 AM
Headache onset
Maximum Pain,
stiffness
and Anxiety
Low Cortisol
level, High
stress
12:Midnight
High alertness
12
Noon

31. Era’s Lucknow Medical College
and Hospital,

32. Special Thanks to Dr. Najah, Dr. Wael,
Dr. R.B.Singh