The epstein Bar virus infects almost everybody on Earth. For the most part, it's relatively minor. Occasionally it causes mono. You get sick, you get better. But it turns out the epstein Bar virus EBV stays in our bodies forever, and in some people, long after their initial infection, EBV winds up causing cancer. In other people it causes multiple sclerosis,
which is not only scary, it's weird. When I think of viral illness, I think you get infected with the virus, maybe you get sick, your immune system responds, and most of the time you get better. That's it. But EBV isn't like that. And one lesson of EBV is maybe we need to think differently about how viruses make us sick, because sometimes they can hide out for decades and then through a complicated and unlucky series of events, they can
do tremendous damage. I'm Jacob Goldstein, and this is Incubation, a show about viruses. Today on the show epstein Bar, let me just say a quick word about pronunciation. In the US we say epstein bar. In the UK they say epstein bar. You will hear both pronunciations in today's show. The show as usual is in two parts. In the second half of the show, we'll hear about this really major breakthrough just from the last few years linking EBV
to multiple sclerosis and other autoimmune diseases. But first we're going to go back to the nineteen sixties. At that time, people knew that viruses could cause cancers in animals. In fact, we talked about that last season in our episode about HPV. In the sixties, no one had ever identified a virus that caused cancer in people. There were some researchers who thought such a thing might exist. One of those researchers was a young British pathologist named Anthony Epstein.
He was extraordinary, a one off, i would say.
Dorothy Crawford was a grad student in Epstein's lab later in the nineteen seventies, and she went on to co write a book about him.
He was supremely self confident. He was highly intelligent, he was intuitive, he was persistent. He was somebody who's going to find the bloody virus if he's.
There, Dorothy says Epstein needed more than intelligence, confidence and persistence to discover the link between viruses and cancer. She says he needed some lucky breaks. Epstein's first big break, according to Dorothy, was when a doctor named Dennis Burkett just happened to give a lecture at the hospital where Epstein worked.
Dennis Burkett was a missionary doctor working in Uganda with children, and he described these large tumors of the jaw that was seemed to be very common among young children in this particular area. He'd never seen anything like it before, and neither had anybody else, and so he went on a jeep ride around Africa to look at the epidemiology of this tumor and tracking the geographical restriction of it.
The tumor only occurred where malaria was what we call hyper endemic, so where malaria occurred all the year round at the same level. And he thought, and many people thought, that maybe it was caused by an infectious agent that was transmitted by mosquitoes, because malaria is transmitted by mosquitoes.
And Burkett gives a lecture at the hospital where Epstein works talking about his work. That's right.
It was the Middlesex hospital where Tony Epstein was working, and Burkett came in nineteen sixty one to give a lecture, and Tony Epstein just happened to see this notice on a noticeboard and went along.
You read in your book that Epstein hears this lecture and he thinks, you know, this may be it, This may be the tumor that is caused by a virus. So what does he do next? What does he do after he hears this lecture?
That very day he approached Burkett and asked him if he could send samples of the tumor to the Middlesex Hospital for him to study. And I mean, it's all very well to just say it like that, And they started arriving. But you know, getting a fresh tumor biopsy from Uganda to the Middlesex Hospital in time for it not to have died, the cells to have died, it's a mean feat on its own, despite everything else. In the mid sixties, exactly in the mid sixties.
Yes, So they start arriving every week, Yes, and Tony Epstein starts looking at them, right, he wants to find some path that is causing this tumor. Right, So what does he start doing.
Well, they were chunks of tumor and he straightway fixed them for the electron microscope. So that he could look at them under the electron microscope. And I just have to add that, I mean, it was dead lucky that the medal Sex had an electron microscope, but because at that time, you know, those machines were like gold dust
and they're incredibly expensive. But pathology at the Middlesex Hospital had one and Tony had access to it, and so he started off preparing them and just looking at the cells and seeing if he could see any viruses in them. And the answer is he couldn't.
He couldn't. Why not? What was going on?
Because there weren't any no virus particles to see in the cells. And so he also put them into tissue culture to see if he could grow the cells, and he couldn't.
Just to be clear, is the idea that like, maybe there were some very small number of virus particles in the tumor cells, and if you could you grow a bunch more cells, you could also get more virus particles so they'd be easier to see.
Yes, that they might increase the number of virus carrying cells, but they didn't. He just basically spent three years getting native results all the way through.
So three years three years is a long time it is to look and not see. I mean, it would be reasonable to conclude, oh, my hypothesis was incorrect, this tumor is not caused by a virus. Like, why doesn't he come to that conclusion?
He would never do that to Every time you asked him why he did it, he said, because I just knew it was right. That's what he always said. It had to be right.
So it's during this period, right that Yvonne Barr comes to work with Tony Epstein, and she of course becomes the other half of Epstein Bar. So tell me about her.
Well, she joined a bit later, I mean as the three years were coming to an end, so she was virtually there when the breakthrough came. She was a scientist from Ireland and her job was to set these cells up in culture. So he looked at them under the electron microscope and he also put them into culture, and as I've already said, nothing grew. But that was her job anyway.
Huh So three years in nothing, nothing, nothing? Then what happened? Then?
What happened was fog fog fog.
A common occurrence in London.
I'm told fog fog?
Yes, why is fog? Why is fog important.
Why, because it delayed the flight that the sample was coming in on. And he throw is particularly low lying and particularly prone to fog, and so they diverted the plane to Manchester. Obviously, it arrived late. It was a Friday afternoon. Everybody had gone home except on He waited for it, and when he got it into the lab, it came in a bottle of transport medium, as we call it, and he held it up to the light and it was all cloudy, and that means to everybody
that it was contaminated with bacteria. And because the temple had been delayed, these bacteria had grown in the culture and it would be useless.
An urmal person would throw it out and wait for the sample next week.
Yes, but Tony didn't do that. He'd got some of the sample out, looked at it under the microscope and did not see any bacteria. He saw free floating tumor cells. And so for the first time ever, he put the free floating cells into a culture. Previously, he'd been putting lumps of tumor into the culture, but there weren't any lumps this time. They'd all shape, the cells had all shaken free on the journey.
So okay, so he finally now can see the cells, he can culture the cells, which he's been on able to do before.
What happened, well, very soon he had enough cells to look at them under the electron microscope, and he looked down the microscope and in the very first grid that he looked at, he saw viruses.
He saw a virus, this thing that he's been looking for and not seeing for three years. Yes, there it is.
In the very first grid square he saw viruses. And he knew immediately that they were herpes viruses by the shape of the virus particles. And he says that he was so excited. He was afraid, you know, he's going to do something wrong, very unusual for Tony, I might say. So he switched the microscope off, went for a walk around the block in the snow, and then came back and turned it on again and made sure that they were still there, and they were.
Wow. You imagine like his hands are shaking or something. He's afraid he's going to knock it down or something.
I suppose, yes, or that he's seeing things. And I can tell you that we now know that only about one percent at most of cells in those cell lines contain virus particles.
You're telling me there's a one in one hundred chants that he would see it in the first grid.
Yes, I am telling you that. Yes, I mean, you know, it's ridiculous, but that's what happened.
So, I mean, this is this is a big moment, right, This is him seeming to find the link between a virus and a tumor.
Yes, but nobody believed it. I mean, I don't suppose I would have believed it either, to be honest.
Why not? Why wouldn't you have believed it?
Because it's so ridiculous?
Tell me more what I don't why why ridiculous?
Well, because at that time, viruses were known to cause things like flu and measles and mumps, you know, and not tumors. I mean it just I can understand why people just did not believe it.
It does feel that way, right, And I guess also the fact that there can be, certainly with some viruses and tumors, a long latency period between infection and the development of the tumor also, I guess makes it harder to believe, right, I mean, harder to prove causality, Like if you know, if you got spots all over your body and then suddenly developed a tumor and be like, oh, okay, I get it, that's the virus. But this doesn't work that way.
Right, Oh, no, it definitely doesn't. And I mean, okay, in berkelnfoma, there's a long incubation period. And what that means is that there must be other factors. The virus is not the only thing needed to cause the tumor. You need other things. And of course the obvious thing in this case is malaria, which immuno suppresses the children and causes them to be you know, more susceptible to this virus.
Aha. So that explains that original link between the tumor and the geographic areas where malaria is especially prevalent. Yes, So tell me about the rest of Tony Epstein's he makes this big discovery, people don't believe him. Eventually they do believe him. How does his career play out?
Well, he was nothing if not single minded.
You know, he was.
Persistent in what he did. He never gave up. He was highly self confident, and he was also an obsessional worker. And so you know, as soon as he in his own mind believed that this was a tumor virus. He knew that what he had to do was make a vaccine to stop the tumor.
Right, it follows, right, Oh my god, we can prevent cancer with the vaccine, yep.
So it's a totally direct way of thinking, and he just went for it. So you know, we're still on a learning curve, frankly, and Tony was part of the learning curve and had a huge, huge impact.
I really appreciate your time of truly fascinating conversation. Thank you so much, No problem. Dorothy Crawford is a retired professor of medical microbiology and co author of the book Cancer Virus, The Story of Epstein Barr Virus. Today, there is still no vaccine for EBV, but people are working on it. Since Epstein's original discovery, EBV has also been linked to other forms of cancer, including Hodgkin's disease and
cancers of the nose, throat, and stomach. Epstein died earlier this year at the age of one hundred and two. As for Yvon Barr, she moved to Australia in nineteen sixty six and became a high school math and science teacher. She died in twenty sixteen, at age eighty three. We'll be back in a minute to discuss new research linking
EBV to multiple sclerosis. It's been clear for decades now that EBV causes certain cancers, and there's been speculation that the virus may also be linked to multiple sclerosis and other autoimmune diseases, but until recently, that's all it was speculation. Bill Robinson is a professor of medicine and chief of
the Division of Immunology and Rheumatology at Stanford. He specializes in autoimmune diseases, and he says for a long time he and his colleagues didn't really buy the idea that EBV causes MS.
We had dismissed it as epiphenomena, meaning ninety four percent of all humans are infected with EBV, and how could it actually be the cause of MASS given only about one in nine hundred people developed mass.
Was that your own view?
That was definitely my view.
Basically, almost everybody has EBV, almost nobody has MS. There's no way there can be a cause of link. The numbers just don't make sense exactly. So this idea is out there for decades really, and only just in the last couple of years, right in twenty twenty two, there were two studies that really seemed compellingly to demonstrate a link between epstein barvirus and multiple sclerosis. And I want to talk about both studies. Of course, I want to talk about the study you did, but before we get
to that, let's talk about the other study. Let's talk about the epidemiological study. Tell me about that work.
Yes, so, in the military, people are getting tested every several years for HIV disease and other things, and the
military has banked samples from those collections. And Alberto Asherio at Harvard School of Public Health, who's been a leader in the field on the association of epstein bar virus with multiple scrosis, completed a lot of paperwork and went through a lot of regulatory requirements and with that received blood samples that were did from individuals who developed multiple scrosis, either in the military or following service, and basically use
these to show that essentially everybody who developed MS was infected with EBV prior to developing MS. Huh More, specifically, they had eight hundred one patients total, and eight hundred out of the eight hundred and one, so ninety nine point nine percent were infected with EBV before they developed clinical multiple scrosis.
So that study shows very elegantly and very compellingly that EBV is basically necessary but not sufficient to get MS.
It doesn't tell us anything about why, about the mechanism, about what's going on, and that's what your work tells us, and I want to get to that, but before we do, let's just talk briefly about multiple sclerosis as a disease, both what happens to patients and also so well what happens to patients sort of clinically and then what happens at the cellular level tell me about multiple sclerosis.
Yeah, so, in MS, the immune system attacks the milin sheath, which is the insulating coating on neurons, and it's essential for effective nerve conduction and thus sensation and you know, muscle movement. I think of the milin sheath as you know, the equivalent of the insulation around a wire. If you cut the insulation on a wire, it's short circuits and doesn't conduct. And likewise, if the immune system attacks and damages the milin sheath on individual nerves, those nerves also
won't conduct. In us won't receive sensory signals or be able to transmit signals to activate muscles in thus move.
So okay, so this is what goes wrong in patients who have multiple sclerosis. Their own immune system attacks the milin sheath that's for their nerves. When you set out to study the role of EBV and MS, what are you what's your hypothesis?
We were very focused on taking the B cells from human multiple scrosis patients and then isolating the specific individual antibodies produced by each B cell.
A B cell is a cell that's part of the immune system, right, So you're looking at the antibodies produced by the B cells in a multiple sclerosis patient.
Yes, And to our great surprise, many of the antibodies were antibodies against viruses, of which EBV was a prominent virus.
Huh. So, in a sense, these are immune cells doing what immune cells are supposed to do. They're creating antibodies to attack pathogens.
And protect that individual against you know, viral pathogens such as E as well as other herpes viruses.
When you put it that way, seems good, right, Oh great, there's a virus has infected my body. My immune cells are creating antibodies to attack that virus. That's what's supposed to happen. Where does it go wrong?
So we discovered that some B cells made antibodies that not only bound to EBV, but they cross bound to human milin, meaning that.
The same antibody could essentially attack both the epstein bar virus and the patient's own the person's own milin.
That's correct.
So was there like a specific moment when you realize that MS patients have these antibodies that attack both EBV and their own milin.
The lead author, Toby Lance on our Nature paper emailed and called when he first found that these antibodies that we had isolated from human MS patients spinal fluid B cells when he found that they bound EBV. The email may call me and they're like, Bill, they're reactive with EBV, and I think we were both shocked.
Yeah, what'd you say? What'd you think when you got that call?
I was floored. I couldn't believe it, and I was like, wow, this is real. Because it's one thing to be statistically or epidemiologically associated, and a second component is to have a mechanistic basis, And our work provided the mechanistic basis by which EBV was causing a subset of MS and thus enables people to further believe the statistical finding that it's strongly associated.
So I know that your study applies to something like a quarter of MS patients. And then, as I understand it, there's other researchers that shows similar things, quite similar things going on in other patients, essentially antibodies that bind you know, both the EBV and tamiolin. Is that right?
Yes, there's several groups studying other antigens that are mimicked by EBV, including our own. And it turns out that EBV infections also associated with other diseases such as systemic loopus or SL and it's also associated with rheumatoid arthritis.
So these are all autoimmune disease, these diseases where the body's immune system is attacking itself. Basically, yes, I mean is this like, are we right now? Are you right now finding the answer to this question that people have been asking for whatever fifty years, eighty years, like, are you finding the virus that is causing autoimmune diseases?
We believe we are, and we are performing experiments to further bear out the mechanisms that would encompass one hundred percent of MS and as well as of lupus and other autoimmune diseases that are EBV associated.
And just to be clear, in these other autoimmune diseases, what are the immune cells? What are the antibodies attacking?
In the other autoimmune diseases, They're not attacking myelin' They're attacking their corresponding tissue anogens. So in loopus, the immune system attacks the nucleus of cells and also the kidney. In rheumatoid arthritis it attacks the joints.
So I mean, why does this one virus, EBV, Why does this one virus cause us to make antibodies that attack so many different parts of the body, Like, what's going on?
You know? I think we don't know. We only you know, hypothesize and speculate. My sense is that given EBV as a herpes virus that's present in a person's B cells as well as epithelial cells for life, and that it's transiently reactivating on a periodic basis, that those properties make it reimmunize the individual multiple times repeatedly over the courses of their life.
So basically, most people get this virus when they're a kid. Right, So you have this virus not just in your body for your whole life, but in your B cells, in your immune cells, and it periodically sort of turns back on basically and causes an immune response. And it's the idea that it's happening again and again and again. That's fundamentally the problem.
I think that that's contributing to the problem.
Almost everybody gets EBV, has EBV. Very few people get autoimmune diseases, certainly relative to the share of people who get EBV. What's going on there? Like, why do only some people get autoimmune diseases if we all have EBV.
Yeah, that's the big question, and that's why more than five years ago we were skeptics that there was any relationship between EBV and MS or these other autoimmune diseases like lupus.
Well, so presumably it's sort of necessary but not sufficient, right, Like you need to have EBV and something else or in some other set of phenomenon, characteristics, risk factors, whatever to develop autoimmune disorders? Do you have a sense of what the other things are.
Recently, investigators in Germany Christian Muntz is showing that some of these classic multiple sclerosis. Genetic risk factors are actually risk factors for inability to mount a robust T cell response to EBV. So they're basically preventing you from having a T cell response that controls the EBV and that's known to be associated with more rounds of reactivation.
Huh. So, just to be clear, T cells are are an immune cell. And so basically this finding is if your body is bad at controlling EBV, if you're genetically bad at controlling EBV, you are more likely to get MS. And that makes sense because if you're bad at controlling EBV, it's gonna you can have more sort of outbreaks within your body of EBV and you're gonna have more rounds of this kind of mutation of antibodies.
Yes, let me give you another recent developments that's profound.
Okay.
A investigator in Germany, professor yorg Chet, gave human lupus patients that had refractory disease that was refractory to all therapies.
Refractory meaning treatment doesn't work.
Treatment doesn't work. Yeah, he gave them a cancer drug that completely depletes their B cells in a profound deep depletion. So to get this drug, you have to be admitted to the hospital for two weeks and receive chemotherapy for a Boemero transplant, and then you receive this drug that attacks all the B cells and removes them all from the body.
So this is like a hardcore, nasty cancer drug.
Yes, okay, but he effectively cured these lupus patients.
Huh.
They're now three years out off all therapies, completely healthy.
So is the basic idea that if you destroy all of the B cells, these B cells that have evolved essentially in a way that is causing them to attack the body, get well, they're extinct. You basically make them go extinct and you get to start again. Is that the.
Idea there, exactly? And they term it an immune reset, which I believe it is because after this Boemere transplant type of B cell depletion merges our naive B cells and then those repopulate the whole repertoire.
Yeah, you're starting from scratch, you get to start over, Yes, and the finding suggest that when you start from scratch, you get better. Your new B cells are not creating antibodies that attack your own body, if I understand.
Correctly, that's correct. But you also have to rego through all of your childhood infections and vaccines.
Oh right, so it's just carpet bomb. You're just carpet bombing the B cells. You're not immune to anything anymore.
That's correct. You're starting from scratch, But compared to having bad lupus or bad autoimmune disease, it's a huge win for the individual patient.
So what you want, presumably in the same way, we have developed targeted cancer therapy, so you don't have to carpet bomb whatever rapidly dividing cells. It seems like if you could just target the B cells you don't like and let all the other B cells be, that.
Would be great, absolutely, and we're working hard to develop therapeutic approaches that would do exactly that.
Thank you so much for your time. I really appreciate it great.
Thanks for featuring EBV in our work.
Bill Robinson is a professor of medicine and chief of the Division of Immunology and Rheumatology at Stanford. Thanks to my guest today, Dorothy Crawford and Bill Robinson next week on incubation. Why did he jump on the boat or train or boat and train or whatever and go to this remote island in the North Sea.
Why did he do that?
A family doctor goes to great lengths to figure out the relationship between chicken pox and shingles. Incubation is a co production of Pushkin Industries and Ruby Studio at iHeartMedia. It's produced by Kate Ferby and Brittany Cronin. The show is edited by Lacy Roberts. It's mastered by Sarah Bruguier, fact checking by Joseph Friedman. Our executive producers are Lacy Roberts and Matt Roman. I'm Jacob Goldstein. Thanks for listening.