Category: Case Study

Improved chronic fatigue symptoms after removal of mercury in patient with increased mercury concentration in hair toxic mineral assay: a case

Abstract:

Clinical manifestations of chronic exposure to organic mercury usually have a gradual onset. As the primary target is the nervous system, chronic mercury exposure can cause symptoms such as fatigue, weakness, headache, and poor recall and concentration. In severe cases chronic exposure leads to intellectual deterioration and neurologic abnormality. Recent outbreaks of bovine spongiform encephalopathy and pathogenic avian influenza have increased fish consumption in Korea. Methyl-mercury, a type of organic mercury, is present in higher than normal ranges in the general Korean population. When we examine a patient with chronic fatigue, we assess his/her methyl-mercury concentrations in the body if environmental exposure such as excessive fish consumption is suspected. In the current case, we learned the patient had consumed many slices of raw tuna and was initially diagnosed with chronic fatigue syndrome. Therefore, we suspected that he was exposured to methyl-mercury and that the mercury concentration in his hair would be below the poisoning level identified by World Health Organization but above the normal range according to hair toxic mineral assay. Our patient’s toxic chronic fatigue symptoms improved after he was given mercury removal therapy, indicating that he was correctly diagnosed with chronic exposure to organic mercury.

 

Source: Shin SR, Han AL. Improved chronic fatigue symptoms after removal of mercury in patient with increased mercury concentration in hair toxic mineral assay: a case. Korean J Fam Med. 2012 Sep;33(5):320-5. doi: 10.4082/kjfm.2012.33.5.320. Epub 2012 Sep 27. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3481032/ (Full article)

 

Pervasive refusal syndrome

Abstract:

We report here on a case of severe pervasive refusal syndrome. This is of interest for three reasons. Firstly, most reported cases are adolescent girls; our case is regarding an adolescent boy. Secondly, he was successfully treated at home and thirdly, the serology showed an apparent infective pre-cursor to the illness with evidence of possible autoimmune serology. A 14-year old boy deteriorated from a picture where diagnosed CFS/ME developed into Pervasive Refusal Syndrome. This included the inability to move or speak, with closed eyes, multiple tics, facial grimacing, heightened sensitivity to noise (hyperacusis) and touch (hyperaesthesia), and inability or unwillingness to eat anything except small amounts of sloppy food. Successful rehabilitation is reported. Finally the issue of nomenclature is discussed, raising the question whether Pervasive Refusal Syndrome would be better renamed in a way that does not imply that the condition is always volitional and oppositional, as this can distract focus away from an alliance between family and clinicians.

 

Source: Wright B, Beverley D. Pervasive refusal syndrome. Clin Child Psychol Psychiatry. 2012 Apr;17(2):221-8. doi: 10.1177/1359104511403680. Epub 2011 Jul 6. https://www.ncbi.nlm.nih.gov/pubmed/21733931

 

Tired with all those supplements?

A 37 year-old patient, who had a history of chronic fatigue syndrome (CFS), was referred to the Clinical Immunology clinic by her general practitioner (GP). Her chief complaint was of severe fatigue following a viral illness 3 months previously. Concerned by her slow recovery she had sought the advice of a private health professional, who performed a series of blood tests and told her that she had insufficient levels of several vitamins and recommended a variety of supplements. In addition to sertraline prescribed by her GP, she was taking eight nutritional supplements. Her weight was stable and she had no history of cough, night sweats, lymphadenopathy, abdominal pain, joint pain, skin rashes or change in bowel habit. Physical examination was unremarkable.

A worsening of her CFS was considered the likely reason for her increased fatigue, but a range of blood tests were requested to exclude other causes (Table 1). These showed a grossly elevated adjusted calcium (3.93 mmol/l), elevated phosphate (1.65 mmol/l) and high urea and creatinine (10.6 and 162 µmol/l, respectively) with normal alkaline phosphatase (48 u/l), and reduced parathyroid hormone (<5 pmol/l). Calcium and creatinine had been normal in blood processed by the laboratory 10 months previously (2.25 and 77 µmol/l, respectively). The patient was admitted under the care of the acute medical team and treated with intravenous fluids and 90 mg of intravenous pamidronate. Her creatinine normalized within a few days and serum calcium over 3 weeks (Figure 1).

You can read the rest of this report here: http://qjmed.oxfordjournals.org/content/104/6/531.long

 

Source: Manson AL1, Chapman N, Wedatilake Y, Balic M, Marway H, Seneviratne SL, Holloway P. Tired with all those supplements? QJM. 2011 Jun;104(6):531-4. doi: 10.1093/qjmed/hcq140. Epub 2010 Aug 13. http://qjmed.oxfordjournals.org/content/104/6/531.long (Full article)

 

Are symptoms of ‘hypoglycemia’ in Chronic Fatigue Syndrome (CFS) associated with hypoglycemia or orthostatic intolerance in young people?

Background: Symptoms of nausea, feeling faint, malaise and mild anxiety are common in young people with CFS and popularly attributed to ‘hypoglycemia’ resulting in various dietary interventions with little reported improvement.

Objectives: To determine whether the symptoms are associated with measured hypoglycaemia using continuous tissue glucose monitoring or whether these symptoms are associated with documented orthostatic intolerance.

Methods: Nine young people with CFS (mean age 20 years) and mean duration of 4.5 years with persistently troublesome symptoms were compared with 10 healthy adult controls without diabetes. Each subject agreed to 3 days Continuous Glucose Monitoring System (Medtronic CGMS). This is routinely used in adolescent diabetics to document food intake, tissue glucose levels and activity levels to monitor control.

Subsequently 8 of these had formal cardiac tilt table testing where heart rate and blood pressure are measured supine and during 70 degree head-up tilt for up to 10 minutes to assess the presence orthostatic intolerance (either postural orthostatic tachycardia (POTS) or neurocardiogenic hypotensive syndrome). If positive, appropriate medical management of increasing salt and fluids, gentle improvement of muscle tone and blood pressure support medications, was implemented.

Results: The tissue glucose was calibrated with the blood glucose and all fell within acceptable normal range. There was statistical (but not clinical) significance in average tissue glucose in CFS subjects. 6% of time in controls and 16.8% in CFS was spent in the range <4mmol/L glucose (95% CI -23% to +2%, p=0.1) suggesting weak evidence for a difference given the variability and small sample size. The reported presence of symptoms throughout the day was not associated with significant reduction in tissue glucose levels.

Six had confirmed evidence for POTS, one for neurocardiogenic syndrome and one for a combination of both. All 8 reported improvement in all symptoms especially nausea, dizziness and malaise with active treatment of their orthostatic intolerance.

Conclusion: This study could not confirm a link between putative symptoms of ‘hypoglycemia’ and documented hypoglycemia. This suggests that symptoms frequently attributed to ‘hypoglycemia’ may be due to orthostatic intolerance and further investigation and management of this condition provides more reported relief for these troublesome symptoms.

Dr Kathy Rowe, Senior Consultant Paediatrician, Department of General Medicine, Royal Children’s Hospital, Melbourne, Victoria, Australia 3052
kathy.rowe@rch.org.au  No conflicts of interest to declare. RCH internally funded.

 

Source: Katherine Rowe, Rebecca Gebert, Susan Donath, Angas Hamer & Fergus Cameron. Are symptoms of ‘hypoglycemia’ in Chronic Fatigue Syndrome (CFS) associated with hypoglycemia or orthostatic intolerance in young people? From: The IACFS/ME 2016 Conference Syllabus.

 

Cervical spine stenosis as a cause of severe ME/CFS and orthostatic intolerance symptoms

Background: Comparatively little has been published on the clinical features and management of severe forms of ME/CFS.

Objectives: To describe the presenting symptoms and neurological examination findings in three young adult women whose disabling ME/CFS symptoms and orthostatic intolerance improved after the recognition and surgical management of cervical spine stenosis (CSS).

Methods: This retrospective case series includes three consecutive individuals who (1) met the Fukuda and criteria for CFS, (2) had evidence of refractory orthostatic intolerance, (3) were unable to work or attend school, and (4) were minimally responsive to medical and psychiatric management. To investigate pathological reflex findings, all underwent MRI evaluations. CSS was considered present if the AP cervical spinal canal diameter (SCD) was less than 10 mm at any level. Overall function was assessed before and after cervical disc replacement surgery using (1) a clinician-assigned Karnofsky score (range 0 to 100) and (2) the SF-36 physical function (PF) subscale score (range 10-30). Higher scores indicate better function on both measures.

Results: Age at onset of symptoms was 12, 29, and 29 years. The onset of ME/CFS was acute in all three. Neurological exam findings included > 3+ (brisk) deep tendon reflexes (DTR) in 2/3, positive Hoffman sign in 2/3, tremor in 2/3, and absent gag reflex in 1/3. Diagnosis was delayed for 6-9 years after the onset of symptoms. Brain MRIs were normal. The youngest patient had congenital CSS with a single level disc protrusion at C5-6 that caused further ventral cord compression and a SCD of 7 mm. Her mother also has cervical stenosis. A second
patient had two disc protrusions at C5-6 and C6-7 with SCD of 7 and 9 mm, and myelomalacia (this patient has a sibling with Chiari I malformation). The third had acquired CSS due to a single level disc bulge at C5-6 (SCD = 8.5 mm).

Improvements were evident within 2 months of single-level cervical disc replacement surgery (one patient also had fusion at an adjacent level). After 16-40 months of follow-up, all reported improved fatigue, cognitive dysfunction, PEM, lightheadedness, and anxiety. The pre- to post-op SF-36 PF scores improved from 13 to 30, 18 to 30, and 16 to 26, respectively, and the Karnofsky scores improved from 40 to 90, 40 to 90, and 50 to 100, respectively. Standing tests conducted at variable intervals from pre- to post-op showed a reduction in the maximal heart rate (HR) change during 5 minutes of standing from 64 to 22 bpm, 42 to 29 bpm, and 34 to 27 bpm, respectively.

Conclusion: This case series draws attention to the potential for CSS to contribute to ME/CFS and orthostatic symptoms, extending work by Heffez in fibromyalgia (Eur Spine J 2004;13:516). Further work is needed to define indications for surgery. However, the improvements in HR and function following surgery emphasize the importance of detecting and treating CSS, especially in the subset of those with ME/CFS whose severe symptoms are refractory to other interventions.

Peter C. Rowe, M.D.
Professor of Pediatrics
Johns Hopkins University School of Medicine/200 N. Wolfe Street/Room 2077
Baltimore, MD 21287
prowe@jhmi.edu

Dr. Rowe is supported by the Sunshine Natural Wellbeing Foundation Professorship in Chronic Fatigue and Related Disorders. No author has a conflict of interest.

 

Source: Peter C. Rowe, M.D*, Colleen L. Marden, Scott Heinlein, PT, Charles Edwards II, M.D. Cervical spine stenosis as a cause of severe ME/CFS and orthostatic intolerance symptoms. Poster presentation, IACFS/ME 2016 conference.

 

A case of chronic fatigue syndrome triggered by influenza H1N1 (swine influenza)

Abstract:

This case report describes an adolescent boy who was diagnosed as suffering from chronic fatigue syndrome 5 months after infection with H1N1 influenza.

 

Source: Vallings R. A case of chronic fatigue syndrome triggered by influenza H1N1 (swine influenza) .J Clin Pathol. 2010 Feb;63(2):184-5. doi: 10.1136/jcp.2009.071944. Epub 2009 Oct 26. https://www.ncbi.nlm.nih.gov/pubmed/19858526

 

Clinical impact of B-cell depletion with the anti-CD20 antibody rituximab in chronic fatigue syndrome: a preliminary case series

Abstract:

BACKGROUND: Chronic fatigue syndrome (CFS) is a disease of unknown aetiology. A patient with CFS had unexpected, marked recovery of CFS symptoms lasting for five months during and after cytotoxic chemotherapy for Hodgkin’s disease. We reasoned that the transient CFS recovery was related to methotrexate treatment, which induces immunomodulation in part through B-cell depletion.

METHODS: In a case series, this patient and two additional CFS patients were B-cell depleted by infusion of the monoclonal anti-CD20 antibody rituximab.

RESULTS: All three had improvement of all CFS symptoms. Patients 1 and 2 had major amelioration from 6 weeks after intervention, patient 3 slight improvement from the same time, but then improved markedly from 26 weeks after intervention. The symptomatic effect lasted until weeks 16, 18 and 44, respectively. At relapse, all were retreated with a single (patient 1) or double rituximab infusion (patients 2 and 3). Again, all three had marked symptom improvement, mimicking their first response. After new symptom recurrence, patients 1 and 2 were given weekly oral methotrexate, patient 1 having effect also from this agent. Patients 1 and 2 were again treated for a third rituximab infusion after new relapse, again with a marked clinical benefit. No unexpected toxicity was seen.

CONCLUSION: These observations suggest that B-lymphocytes are involved in CFS pathogenesis for a subset of patients. Benefit for all CFS symptoms, the delayed symptom relief following B-cell depletion, the kinetics of relapses, and the effect also from methotrexate treatment, provide suggestive evidence that B-cells play a significant role in the ongoing clinical features, and that CFS may be amenable to therapeutic interventions aimed at modifying B-cell number and function. More systematic investigations of this therapeutic strategy, and of its biological basis, are now needed.

 

Source: Fluge Ø, Mella O. Clinical impact of B-cell depletion with the anti-CD20 antibody rituximab in chronic fatigue syndrome: a preliminary case series. BMC Neurol. 2009 Jul 1;9:28. doi: 10.1186/1471-2377-9-28. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2711959/ (Full article)

 

Association of chronic fatigue syndrome and acute psychotic episode: is it coincidental?

Sir: We present a case of a woman who had suffered from chronic fatigue syndrome (CFS) for several years and was admitted for an acute psychotic episode. This association has rarely been described.

Case report. Ms. A, a 43-year-old mother of 2 children, was admitted in January 2006 with delusion and hallucinations following a period of exacerbated fatigue. She was afraid that her children would be abducted by the devil and tried to protect them. She begged her children not to get near the walls of her house for fear that the devil could erupt from the walls and take them.

Ms. A first experienced persistent fatigue 3 years before admission. Prior to this, she had been a very active woman. She had to stop working and was able to participate in only very few activities during the day. She attributed her fatigue to the overwhelming task of educating her hyperkinetic 9-year-old son.

She had a depressive episode of several months’ duration 10 years before admission, following an abortion of a pregnancy involving a malformed child. This episode had subsided without relapse. She had infectious mononucleosis 20 years before admission. A polysomnographic test 2 years before admission showed many awakenings interrupting Ms. A’s sleep pattern. She was then diagnosed with chronic fatigue syndrome according to the criteria of Holmes1 and Fukuda.2 Antidepressive medication was prescribed; it alleviated the secondary depressive symptoms but had no impact on her fatigue complaint.

During Ms. A’s hospitalization, her blood analysis results were unremarkable, excluding common organic causes of fatigue. Results of her neurologic examination at admission were normal. Her brain computed tomography (CT) scan showed frontal cortical atrophy, but neuropsychological tests failed to show major cognitive impairments.

Olanzapine was prescribed at the dosage of 15 mg/day, and her symptoms gradually subsided. She was discharged 1 month after admission, totally free of her psychotic symptoms. Her neuroleptic treatment was changed to 10 mg of aripiprazole because of excessive weight gain. Aripiprazole was as effective as olanzapine but allowed her to return to her usual weight. The treatment was gradually stopped after 1 year, with no recurrence of psychotic symptoms.

The association between CFS and psychosis has rarely been described. We are aware of only 2 other case reports. The first describes a 28-year-old man who developed CFS after mononucleosis and suffered afterward from a manic episode with psychotic characteristics.3

You can read the rest of this article here: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2629064/

 

Source: Kornreich C, Szombat M, Vandriette YM, Dan B. Association of chronic fatigue syndrome and acute psychotic episode: is it coincidental? Prim Care Companion J Clin Psychiatry. 2008;10(5):412. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2629064/ (Full article)

 

Chronic fatigue syndrome and complement activation

Abstract:

This report describes a case of chronic fatigue syndrome (CFS) that followed a well-documented episode of acute Epstein-Barr virus (EBV) mononucleosis. All aetiological tests for chronic fatigue were found to be negative or normal, as were immunological tests. After 2 years of chronic fatigue following the acute illness, measurements of complement split products were performed to test for complement activation. These were positive and remained positive for 14 months, after which the patient then recovered from CFS.

 

Source: Geller RD, Giclas PC. Chronic fatigue syndrome and complement activation. BMJ Case Rep. 2009;2009. pii: bcr08.2008.0819. doi: 10.1136/bcr.08.2008.0819. Epub 2009 Mar 17. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3028106/ (Full article)

 

Chronic fatigue syndrome with autoantibodies–the result of an augmented adjuvant effect of hepatitis-B vaccine and silicone implant

Abstract:

BACKGROUND: Chronic fatigue syndrome (CFS) that defines by prolonged fatigue and other manifestations, was recently integrated into a spectrum of central sensitivity syndromes including several diseases as fibromylagia. CFS etiology is multi-factorial commonly triggered by infectious agents. Vaccines, induce an immune response similarly to infections, and may trigger just like infections autoimmune diseases, CFS and fibromyalgia. Furthermore vaccines contain an adjuvant which enhances their immune stimulation.

CASE PRESENTATION: A 56-year-old woman was diagnosed with CFS accompanied by fibromyalgia, demyelination and autoantibodies. Her illness begun following the 2nd dose of hepatitis-B vaccine, and was aggravated by the 3rd vaccination. She underwent silicone breast implantation 6 years before vaccination with no adverse events. However, between the 2nd and 3rd vaccination she suffered a breast injury with local inflammation. Upon explanation of her breast implants silicone leak was observed.

DISCUSSION: Vaccines have been reported to precede CFS mainly following exposure to multiple vaccinations (e.g. the Gulf war syndrome), or as an adverse response to the vaccine adjuvant (e.g. the macrophagic myofasciitis syndrome). Silicone is considered an adjuvant to the immune system, and may induce “the adjuvant disease”. Silicone implant, especially silicone leak relationship with autoimmunity and CFS has been the focus of considerable debates.

CONCLUSION: Our patient illness started following hepatitis-B vaccine, suggesting that it was caused or accelerated by vaccination. In parallel to vaccination our patient suffered from breast injury, which might represent the time of silicone leak. The exposure to the adjuvant, silicone, might have augmented her immune response to the vaccine. To the best of our knowledge this is the first case of combined adverse effect to vaccine and silicone. Vaccine safety in individuals with silicone implants requires further studies.

 

Source: Nancy AL, Shoenfeld Y. Chronic fatigue syndrome with autoantibodies–the result of an augmented adjuvant effect of hepatitis-B vaccine and silicone implant. Autoimmun Rev. 2008 Oct;8(1):52-5. doi: 10.1016/j.autrev.2008.07.026. Epub 2008 Aug 24. https://www.ncbi.nlm.nih.gov/pubmed/18725327