Ignorance about post-exertional malaise and continued conflation of ME/CFS with chronic fatigue harms patients and stymies research progress

Dear Editor,

There are numerous issues with the opinion piece by Miller and coauthors. Most concern longstanding fallacies about the nature of ME/CFS and what patients believe about their illness, which — again — need to be corrected. I’d like to focus on just one: The defining and cardinal feature of ME/CFS is not fatigue, but rather post-exertional malaise (PEM).

PEM, sometimes referred to as post-exertional symptom exacerbation (PESE), can be defined as episodes during which people with ME/CFS experience significant worsening of existing symptoms and/or onset of new symptoms following amounts of physical or mental exertion or sensory stimuli that they could easily tolerate before the illness [1]. The length and severity of an episode of PEM are out of proportion to the amount of exertion or stimulus that triggered it; in severe or very severe ME/CFS patients, PEM may be triggered by, for example, short conversations with their carers or brief exposure to bright light, and these episodes may last week, months, or longer.

PEM remains poorly understood, but the concept and terminology have over recent years become much more mainstream, owing to the high prevalence of PEM in long covid [2]. The consensus opinion among ME/CFS patients is that daily activities and sensory input should be managed in such a way as to minimise PEM, because PEM severely impacts quality of life and can in some cases lead to further long-term deterioration in patients’ health and functional capacity. This concept forms the basis of pacing, an energy management strategy recommended by NICE [3].

In their opinion piece, Miller and coauthors ignore PEM when listing common symptoms of ME/CFS. This is an attempt to continue framing this illness as belonging to a family of ‘fatiguing conditions’, which, along with other ‘medically unexplained symptoms’, they argue can be treated with psychological interventions and rehabilitation.

Read the rest of this letter here: https://www.bmj.com/content/389/bmj.r977/rr-6

The risk of blaming patients for their lack of recovery

Dear Editor,

In their article on the management of patients with severe myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS), Miller et al. propose a biopsychosocial model in which “a gradual, controlled approach to increasing activity is an important part of rehabilitation.” This approach, however, is far from new and has been tested in randomized trials with limited success.

The PACE study, for example, examined fourteen sessions of cognitive behaviour therapy (CBT) or graded exercise therapy (GET), each combined with specialist medical care. Treatment aimed to help ME/CFS patients gradually resume physical activities, address unhelpful cognitions, and reverse deconditioning. Recovery rates for GET and CBT were low and did not differ significantly from the control group, with rates of 4%, 7%, and 3%, respectively, as defined by the study’s pre-registered recovery criteria. [1] Employment and fitness data also showed no clinically significant improvement. [2]

Read the full letter by Michiel Tack here: https://www.bmj.com/content/389/bmj.r977/rr-3

How a Clinician Makes a Diagnosis for Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS)

Abstract:

This chapter describes how a clinician with experience of myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) makes a diagnosis of the condition in the absence of a routine laboratory diagnostic test.

Source: Vallings R. How a Clinician Makes a Diagnosis for Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS). Methods Mol Biol. 2025;2920:3-11. doi: 10.1007/978-1-0716-4498-0_1. PMID: 40372674. https://link.springer.com/protocol/10.1007/978-1-0716-4498-0_1

Using the Ratio of Phosphorylated to Non-phosphorylated Forms of Stress Kinase PKR as a Potential Diagnostic Test for ME/CFS

Abstract:

Myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) is a complex illness characterized by a set of mainly neurological symptoms lasting for over 6 months. Currently, there is no definitive laboratory diagnostic test readily accessible to all clinicians and patients, and so clinical diagnosis occurs only after an exhaustive process of exclusion of all other possible causes of the varied symptoms experienced by the patient.

Here we present the development of a method that uses specific antibodies able to identify a changed ratio of phosphorylated and active protein kinase R in the peripheral blood monocyte cells (PBMCs) and neutrophil cells from a small group of ME/CFS sufferers, compared to age and sex-matched controls.

Protein kinase R (PKR) is an RNA-activated immune protein and stress kinase that has been observed to be present in its cleaved, auto-phosphorylated, and active form in past ME/CFS studies. After further validation, the activation status of PKR detected via specific antibodies in an ELISA format has potential for a simple readily accessible diagnostic tool for the early acute stage of ME/CFS illness, or as a long-term measure to evaluate the disease status.

Source: Sweetman E, Tate WP. Using the Ratio of Phosphorylated to Non-phosphorylated Forms of Stress Kinase PKR as a Potential Diagnostic Test for ME/CFS. Methods Mol Biol. 2025;2920:13-28. doi: 10.1007/978-1-0716-4498-0_2. PMID: 40372675. https://link.springer.com/protocol/10.1007/978-1-0716-4498-0_2

Using Single-Cell Raman Microspectroscopy to Profile Human Peripheral Blood Mononuclear Cells

Abstract:

A reliable, validated test would enhance our ability to treat and research chronic conditions. Early and accurate diagnosis would provide an entry point into clinical care, give access to benefits, remove the stigma associated with these conditions, and importantly, provide researchers with a fundamental tool they require to study these heterogeneous disorders.

In this chapter, we describe how Raman microspectroscopy can be utilised to study the biology of peripheral blood mononuclear cells (PBMCs) isolated from human blood samples. Using machine learning approaches, the data generated can be used to attempt to separate different patient and control groups, subgroups within a patient cohort, and identify differences in intracellular metabolites which may provide clues about disease mechanisms.

Source: Gan E, Stoker M, Guo E, Morten KJ, Xu J. Using Single-Cell Raman Microspectroscopy to Profile Human Peripheral Blood Mononuclear Cells. Methods Mol Biol. 2025;2920:29-37. doi: 10.1007/978-1-0716-4498-0_3. PMID: 40372676. https://link.springer.com/protocol/10.1007/978-1-0716-4498-0_3

MicroRNA Profiling of Blood Extracellular Vesicles in ME/CFS

Abstract:

Myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) is a chronic debilitating neuroimmune disease affecting many organs and systems which, in the absence of validated biomarkers, remains diagnosed by clinical criteria. Extracellular vesicles (EV) in blood come from practically all cells in our body and therefore may carry the disease-specific biomarkers needed for the diagnosis of ME.

This chapter presents the methodology used on a single pilot study performed to evaluate this possibility to describe a workflow for EV isolation and the analysis of the miRNAs within, which could serve to interrogate additional cohorts of ME/CFS. Among the diverse nature of EV contents miRNAs may constitute a prominent regulatory layer in the development and progress of complex diseases such as ME/CFS, and therefore their study should be further pursued.

Source:Ljungström M, Nathanson L, Oltra E. MicroRNA Profiling of Blood Extracellular Vesicles in ME/CFS. Methods Mol Biol. 2025;2920:39-55. doi: 10.1007/978-1-0716-4498-0_4. PMID: 40372677. https://link.springer.com/protocol/10.1007/978-1-0716-4498-0_4

Deep Immunophenotyping in ME/CFS Using Spectral Flow Cytometry

Abstract:

Immune dysfunction is reported to play a significant role in the etiology of myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS). To gain an understanding of the underlying immune abnormalities associated with this complex condition, a comprehensive approach for characterizing immune cell subsets and their inferred functional states is essential.

We developed a high-dimensional flow cytometry method that enables detailed immunophenotyping of peripheral blood mononuclear cells (PBMCs) from ME/CFS patients. By simultaneously measuring over 40 markers on individual cells within one sample, this approach provides a comprehensive assessment of immune cell subsets, incorporating effector or functional states, to enable assessment of their potential roles in disease pathogenesis.

Source: Gibson A, Chometon TQ, Damani T, Brooks AES. Deep Immunophenotyping in ME/CFS Using Spectral Flow Cytometry. Methods Mol Biol. 2025;2920:59-82. doi: 10.1007/978-1-0716-4498-0_5. PMID: 40372678. https://link.springer.com/protocol/10.1007/978-1-0716-4498-0_5

Analysis of Transient Receptor Potential Ion Channels in ME/CFS

Abstract:

This chapter provides a comprehensive overview of methodologies currently employed to study ion channels, particularly transient receptor potential melastatin 3 (TRPM3) in the context of myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS). Sample preparation involves the collection of whole blood, separation of peripheral blood mononuclear cells (PBMCs) via density gradient centrifugation, and isolation of natural killer (NK) cells.

Protein expression analysis utilizes flow cytometry, liquid chromatography-mass spectrometry (LC-MS), western blotting, and immunofluorescence techniques. Functional analysis focuses on calcium imaging and electrophysiology techniques to investigate ion channel responses to pharmacological stimuli.

The authors highlight that some experimental protocols included within this chapter require specialized training and equipment. In order to replicate these protocols extended training is advised, specifically when attempting electrophysiology experimentation. The use of advanced techniques for detailed analysis provides insights into ion channel function and potential implications in the pathomechanism of ME/CFS offering avenues for further research and therapeutic exploration.

Source: Eaton-Fitch N, Muraki K, Sasso EM, Magawa C, Marshall-Gradisnik S. Analysis of Transient Receptor Potential Ion Channels in ME/CFS. Methods Mol Biol. 2025;2920:83-99. doi: 10.1007/978-1-0716-4498-0_6. PMID: 40372679. https://link.springer.com/protocol/10.1007/978-1-0716-4498-0_6

Stress-Induced Changes in Immune Signatures in ME/CFS Patients Determined by Transcriptome Analysis

Abstract:

Myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) is a chronic, complex multi-organ illness characterized by unexplained debilitating fatigue and post-exertional malaise (PEM). We evaluated transcriptomic changes in peripheral blood mononuclear cells (PBMC) of ME/CFS patients undergoing an exercise challenge and explored the transcriptomic response to exercise and recovery in PBMC of ME/CFS patients, as compared to healthy controls using RNA sequencing technology. As transcriptomic changes in ME/CFS patients are still in the phase of discovery, analysis of data has to be stringent, and the most important results have to be validated by a different technology, such as real-time PCR or NanoString.

Source: Gamer J, Van Booven D, Zarnowski O, Perez M, Frank J, Pangeni RP, Collado F, Klimas NG, Oltra E, Nathanson L. Stress-Induced Changes in Immune Signatures in ME/CFS Patients Determined by Transcriptome Analysis. Methods Mol Biol. 2025;2920:103-112. doi: 10.1007/978-1-0716-4498-0_7. PMID: 40372680. https://link.springer.com/protocol/10.1007/978-1-0716-4498-0_7

Quantitative Proteomics on Immune Cells of ME/CFS Patients Using SWATH-MS

Abstract:

Proteomics is one of the “omics” disciplines that has provided molecular insights into the pathophysiology of myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS). Here we describe a complete SWATH-MS workflow for the quantitative profiling of proteins extracted from peripheral mononuclear blood cells to investigate proteomic alterations in ME/CFS. This workflow covers all steps of sample preparation, data acquisition, and data analysis.

We describe the process of generating a comprehensive spectral library from a pre-fractionated peptide reference sample followed by the acquisition of DIA data sets of individual samples using a 5600+ TripleTOF mass spectrometer. Examples of both library-based and library-free data analysis pipelines are presented based on the PeakView/MarkerView software package (commercial) and DIA-NN (free) software respectively.

Source: Kumar A, Peppercorn K, Kleffmann T. Quantitative Proteomics on Immune Cells of ME/CFS Patients Using SWATH-MS. Methods Mol Biol. 2025;2920:113-140. doi: 10.1007/978-1-0716-4498-0_8. PMID: 40372681. https://link.springer.com/protocol/10.1007/978-1-0716-4498-0_8