Symptom Clusters in ME/CFS Reflect Distinct Neuroimmune and Autonomic Pathophysiological Mechanisms: A Translational Model

Symptom Clusters in ME/CFS Reflect Distinct Neuroimmune and Autonomic Pathophysiological Mechanisms: A Translational Model | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Symptom Clusters in ME/CFS Reflect Distinct Neuroimmune and Autonomic Pathophysiological Mechanisms: A Translational Model Dr. Lotte Habermann-Horstmeier, Lukas Maximilian Horstmeier This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8491822/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 28 Apr, 2026 Read the published version in Journal of Translational Medicine → Version 1 posted 4 You are reading this latest preprint version Abstract Background Myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) is a debilitating multisystem disease characterized by heterogeneous symptom patterns. Previous work suggested that specific symptoms tend to co‑occur, pointing toward underlying biological mechanisms. This study aimed to empirically validate literature‑based, hypothesis‑driven symptom clusters and assess whether they reflect distinct neuroimmune and autonomic pathophysiological pathways. Methods Symptom data from 748 adults with ME/CFS (≥ 20 years) participating in the APAV‑ME/CFS study were analyzed. Symptoms were assigned to predefined mechanistic groups informed by current pathophysiological hypotheses. Exploratory and Confirmatory Factor Analyses, followed by Structural Equation Modeling (SEM), evaluated the coherence, distinctiveness, and hierarchical structure of each cluster. Robustness was tested using a stratified, randomized training dataset. Results A coherent Brain factor (brain fog, sensory hypersensitivity, visual disturbances, sleep disturbances, headaches) showed excellent fit (RMSEA = 0.021; CFI = 0.996). Gastrointestinal symptoms demonstrated stronger internal consistency than Immune symptoms, and model comparisons supported a two‑factor Gut – Immune structure. Across all analyses, symptom groups emerged as internally consistent and statistically distinct. A higher‑order SEM including a common latent factor yielded excellent fit for the Vegetative (autonomic) symptom complex. Conclusions The findings support ME/CFS as a complex neuroimmune and autonomic multisystem disorder and demonstrate that symptom clusters map onto functional biological systems. Mechanism‑aligned symptom subgrouping may facilitate pathophysiology‑guided diagnostics, stratification, and individualized therapeutic development. Myalgic Encephalomyelitis/Chronic Fatigue Syndrome symptom clusters neuroimmune mechanisms autonomic dysfunction translational modelling factor analysis structural equation modeling Full Text Supplementary Files ResultswithtrainigdataImmuneGut.docx ResultswithtrainigdataGut.docx ResultswithtrainingdataBrain.docx ResultswithtrainingdataImmune.docx ResultswithtrainingdataVegetative.docx Cite Share Download PDF Status: Published Journal Publication published 28 Apr, 2026 Read the published version in Journal of Translational Medicine → Version 1 posted Reviewers agreed at journal 28 Jan, 2026 Reviewers invited by journal 28 Jan, 2026 Editor assigned by journal 26 Jan, 2026 First submitted to journal 05 Jan, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8491822","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":582121317,"identity":"d4a8b609-2495-4ffd-8374-49e830c374dc","order_by":0,"name":"Dr. Lotte Habermann-Horstmeier","email":"data:image/png;base64,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","orcid":"https://orcid.org/0000-0001-6912-7999","institution":"Villingen Institute of Public Health","correspondingAuthor":true,"prefix":"Dr.","firstName":"Lotte","middleName":"","lastName":"Habermann-Horstmeier","suffix":""},{"id":582121318,"identity":"9b0768e2-7bad-4e6f-94bb-0ba708a282b7","order_by":1,"name":"Lukas Maximilian Horstmeier","email":"","orcid":"","institution":"Universitätsklinikum Freiburg: Albert-Ludwigs-Universitat Freiburg Universitatsklinikum Freiburg","correspondingAuthor":false,"prefix":"","firstName":"Lukas","middleName":"Maximilian","lastName":"Horstmeier","suffix":""}],"badges":[],"createdAt":"2025-12-31 18:53:58","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8491822/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8491822/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12967-026-08159-1","type":"published","date":"2026-04-28T15:57:04+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":108437554,"identity":"19bb637e-5be4-47c0-9457-c00e8a3c21c0","added_by":"auto","created_at":"2026-05-04 15:59:10","extension":"pdf","order_by":1,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":716072,"visible":true,"origin":"","legend":"","description":"","filename":"ManuscriptJTM05.01.2026.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8491822/v1_covered_a2245ee4-2796-4544-81ea-4e4da48b2a46.pdf"},{"id":101656000,"identity":"a55e1235-3e48-43d0-9141-d84c054db50f","added_by":"auto","created_at":"2026-02-02 10:05:59","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":233131,"visible":true,"origin":"","legend":"","description":"","filename":"ResultswithtrainigdataImmuneGut.docx","url":"https://assets-eu.researchsquare.com/files/rs-8491822/v1/af6412a49a2c40526b7f76ab.docx"},{"id":101656004,"identity":"18a245d7-948c-49e8-9ce9-96232a669c2e","added_by":"auto","created_at":"2026-02-02 10:06:00","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":176901,"visible":true,"origin":"","legend":"","description":"","filename":"ResultswithtrainigdataGut.docx","url":"https://assets-eu.researchsquare.com/files/rs-8491822/v1/1a36c944b07d29e71bde189f.docx"},{"id":101656002,"identity":"27a50340-15fb-4bb0-b4e1-79982a79e6e4","added_by":"auto","created_at":"2026-02-02 10:05:59","extension":"docx","order_by":3,"title":"","display":"","copyAsset":false,"role":"supplement","size":383877,"visible":true,"origin":"","legend":"","description":"","filename":"ResultswithtrainingdataBrain.docx","url":"https://assets-eu.researchsquare.com/files/rs-8491822/v1/bdf284daed81e92defc1f617.docx"},{"id":101656003,"identity":"bf86f0f6-c275-4eba-b7e3-000f510153d7","added_by":"auto","created_at":"2026-02-02 10:06:00","extension":"docx","order_by":4,"title":"","display":"","copyAsset":false,"role":"supplement","size":191933,"visible":true,"origin":"","legend":"","description":"","filename":"ResultswithtrainingdataImmune.docx","url":"https://assets-eu.researchsquare.com/files/rs-8491822/v1/26c994d44bce987ff2aa9f96.docx"},{"id":101656001,"identity":"1450fe27-3afd-4a3f-a097-f657fc0a2eb9","added_by":"auto","created_at":"2026-02-02 10:05:59","extension":"docx","order_by":5,"title":"","display":"","copyAsset":false,"role":"supplement","size":211289,"visible":true,"origin":"","legend":"","description":"","filename":"ResultswithtrainingdataVegetative.docx","url":"https://assets-eu.researchsquare.com/files/rs-8491822/v1/89e4a5b80b6cfb540f6aa5ff.docx"}],"financialInterests":"","formattedTitle":"Symptom Clusters in ME/CFS Reflect Distinct Neuroimmune and Autonomic Pathophysiological Mechanisms: A Translational Model","fulltext":[],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":false,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":true,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":true,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"journal-of-translational-medicine","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jtrm","sideBox":"Learn more about [Journal of Translational Medicine](http://translational-medicine.biomedcentral.com)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/jtrm/default.aspx","title":"Journal of Translational Medicine","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Myalgic Encephalomyelitis/Chronic Fatigue Syndrome, symptom clusters, neuroimmune mechanisms, autonomic dysfunction, translational modelling, factor analysis, structural equation modeling","lastPublishedDoi":"10.21203/rs.3.rs-8491822/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8491822/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eMyalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) is a debilitating multisystem disease characterized by heterogeneous symptom patterns. Previous work suggested that specific symptoms tend to co‑occur, pointing toward underlying biological mechanisms. This study aimed to empirically validate literature‑based, hypothesis‑driven symptom clusters and assess whether they reflect distinct neuroimmune and autonomic pathophysiological pathways.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eSymptom data from 748 adults with ME/CFS (\u0026ge;\u0026thinsp;20 years) participating in the APAV‑ME/CFS study were analyzed. Symptoms were assigned to predefined mechanistic groups informed by current pathophysiological hypotheses. Exploratory and Confirmatory Factor Analyses, followed by Structural Equation Modeling (SEM), evaluated the coherence, distinctiveness, and hierarchical structure of each cluster. Robustness was tested using a stratified, randomized training dataset.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eA coherent \u003cem\u003eBrain\u003c/em\u003e factor (brain fog, sensory hypersensitivity, visual disturbances, sleep disturbances, headaches) showed excellent fit (RMSEA\u0026thinsp;=\u0026thinsp;0.021; CFI\u0026thinsp;=\u0026thinsp;0.996). Gastrointestinal symptoms demonstrated stronger internal consistency than \u003cem\u003eImmune\u003c/em\u003e symptoms, and model comparisons supported a two‑factor \u003cem\u003eGut\u003c/em\u003e\u0026ndash;\u003cem\u003eImmune\u003c/em\u003e structure. Across all analyses, symptom groups emerged as internally consistent and statistically distinct. A higher‑order SEM including a common latent factor yielded excellent fit for the \u003cem\u003eVegetative\u003c/em\u003e (autonomic) symptom complex.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eThe findings support ME/CFS as a complex neuroimmune and autonomic multisystem disorder and demonstrate that symptom clusters map onto functional biological systems. Mechanism‑aligned symptom subgrouping may facilitate pathophysiology‑guided diagnostics, stratification, and individualized therapeutic development.\u003c/p\u003e","manuscriptTitle":"Symptom Clusters in ME/CFS Reflect Distinct Neuroimmune and Autonomic Pathophysiological Mechanisms: A Translational Model","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-02-02 10:05:54","doi":"10.21203/rs.3.rs-8491822/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewerAgreed","content":"","date":"2026-01-29T02:39:35+00:00","index":0,"fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-01-29T02:30:53+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-01-27T03:58:40+00:00","index":"","fulltext":""},{"type":"submitted","content":"Journal of Translational Medicine","date":"2026-01-05T09:35:19+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"journal-of-translational-medicine","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jtrm","sideBox":"Learn more about [Journal of Translational Medicine](http://translational-medicine.biomedcentral.com)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/jtrm/default.aspx","title":"Journal of Translational Medicine","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"0560a47c-35fd-4481-bcbc-017cd3b81afd","owner":[],"postedDate":"February 2nd, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-05-04T15:58:56+00:00","versionOfRecord":{"articleIdentity":"rs-8491822","link":"https://doi.org/10.1186/s12967-026-08159-1","journal":{"identity":"journal-of-translational-medicine","isVorOnly":false,"title":"Journal of Translational Medicine"},"publishedOn":"2026-04-28 15:57:04","publishedOnDateReadable":"April 28th, 2026"},"versionCreatedAt":"2026-02-02 10:05:54","video":"","vorDoi":"10.1186/s12967-026-08159-1","vorDoiUrl":"https://doi.org/10.1186/s12967-026-08159-1","workflowStages":[]},"version":"v1","identity":"rs-8491822","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8491822","identity":"rs-8491822","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}