Lyme disease in a British referral clinic

Abstract:

BACKGROUND: Concerns about over-diagnosis and inappropriate management of Lyme disease (LD) are well documented in North America and supported by clinical data. There are few parallel data on the situation in the UK.

AIM: To describe the patterns of referral, investigation, diagnosis and treatment of patients with suspected LD referred to an infectious disease unit in Liverpool, UK. Previous management by National Health Service (NHS) and non-NHS practitioners was reviewed.

DESIGN: Descriptive study conducted by retrospective casenotes review.

METHODS: Retrospective case notes review of adults referred with possible LD to an infectious disease unit in Liverpool, UK, over 5 years (2006-2010).

RESULTS: Of 115 patients, 27 (23%) were diagnosed with LD, 38 (33%) with chronic fatigue syndrome (CFS) and 13 (11%) with other medical conditions. No specific diagnosis could be made in 38 (33%). At least 53 unnecessary antibiotic courses had been given by non-NHS practitioners; 21 unnecessary courses had been prescribed by NHS practitioners. Among 38 patients, 17 (45%) with CFS had been misdiagnosed as having LD by non-NHS practitioners.

CONCLUSION: A minority of referred patients had LD, while a third had CFS. LD is over-diagnosed by non-specialists, reflecting the complexities of clinical and/or laboratory diagnosis. Patients with CFS were susceptible to misdiagnosis in non-NHS settings, reinforcing concerns about missed opportunities for appropriate treatment for this group and about the use of inappropriate diagnostic modalities and anti-microbials in non-NHS settings.

Comment in: [Borreliosis]. [Orthopade. 2013]

 

Source: Cottle LE, Mekonnen E, Beadsworth MB, Miller AR, Beeching NJ. Lyme disease in a British referral clinic. QJM. 2012 Jun;105(6):537-43. doi: 10.1093/qjmed/hcs003. Epub 2012 Feb 1. http://qjmed.oxfordjournals.org/content/105/6/537.long (Full article)

 

Coping styles in chronic fatigue syndrome: findings from a population-based study

Chronic fatigue syndrome (CFS) is a common and debilitating illness [1]. As yet the pathophysiology of CFS remains inchoate, so pharmacologic management aims to alleviate symptoms and is not curative. Cognitive-behavioral therapy and graded exercise therapy appear to be the most effective treatments for CFS [2]. Such therapies require that patients understand, adhere to and practice specific activities to manage their thoughts and expenditure of physical energy. This necessary understanding and commitment are heavily impacted by patients’ coping styles and concomitant psychopathology. In a previous population-based study, we found that people with CFS were significantly more likely to use maladaptive everyday coping strategies than non-fatigued matched controls [3]. In another population-based study, we found that about 60% of people with CFS suffered psychiatric comorbidity; in particular affective and anxiety disorders [4], and displayed maladaptive personality styles [5]. In the current population-based study, we examined coping styles in CFS and how these are affected by depression and anxiety.

You can read the rest of this article here: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3701445/

 

Source: Nater UM, Maloney E, Lin JM, Heim C, Reeves WC. Coping styles in chronic fatigue syndrome: findings from a population-based study. Psychother Psychosom. 2012;81(2):127-9. doi: 10.1159/000329996. Epub 2012 Feb 2. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3701445/ (Full article)

 

Adrenal histoplasmosis: a case series and review of the literature

Abstract:

Adrenal histoplasmosis is an uncommon mycotic disease typically caused by Histoplasma capsulatum. The objective was to determine the clinicopathological findings in adrenal histoplasmosis.

Pathological records were searched from the database at the Department of Pathology, Faculty of Medicine Ramathibodi Hospital, Mahidol University from 1993 to 2008 for cases of adrenal histoplasmosis. The keywords were “histoplasmosis” and “adrenal gland”.

Adrenal histoplasmosis was diagnosed by histopathology and Gomori-Grocott methenamine silver staining. Histoplasma capsulatum was confirmed by tissue culture and/or serology. The authors report seven cases of adrenal histoplasmosis in immunocompetent patients. The mean age at diagnosis was 67 years. All patients presented as chronic fatigue syndrome.

The onset of symptoms ranged from one to three months. Addison’s disease was found in adrenal histoplasmosis in one case (14.3%). The computed tomography revealed adrenal nodules measuring 1.2 to 7.8 cm in diameter.

The histopathology showed granulomatous inflammation with caseous necrosis. Culture of adrenal tissue from two patients revealed Histoplasma capsulatum. Serum Histoplasma antibodies were positive in four cases. A cure was accomplished in 6 out of 7 cases (85.7%). The patients were followed up for 2.5 to 16.5 years.

 

Source: Larbcharoensub N, Boonsakan P, Aroonroch R, Rochanawutanon M, Nitiyanant P, Phongkitkarun S, Poonvutikul S, Watcharananan SP, Ngarmukos C. Adrenal histoplasmosis: a case series and review of the literature. Southeast Asian J Trop Med Public Health. 2011 Jul;42(4):920-5. https://www.ncbi.nlm.nih.gov/pubmed/22299474

 

Alternative diagnoses to chronic fatigue syndrome in referrals to a specialist service: service evaluation survey

Abstract:

OBJECTIVE: To assess the accuracy of diagnoses made by referrers to a chronic fatigue syndrome (CFS) service.

DESIGN: Retrospective service evaluation surveys of both rejected referral letters and medical case-notes after full clinical assessment.

SETTING: A specialist CFS clinic in London, UK.

PARTICIPANTS: In the first survey, we assessed rejected referral letters between March 2007 and September 2008. In the second survey, we ascertained the primary diagnosis made in case-notes of 250 consecutive new patients assessed between April 2007 and November 2008.

MAIN OUTCOME MEASURES: Reasons for rejection of referrals and primary diagnosis in those assessed.

RESULTS: In the first survey, 154 out of 418 referrals (37%) were rejected. Of these, 77 out of the available 127 referrals (61%) had a likely alternative diagnosis. In the second survey of clinically assessed patients, 107 (43%) had alternative medical/psychiatric diagnoses, while 137 out of 250 (54%) patients received a diagnosis of CFS. The commonest alternative medical diagnoses of those assessed were sleep disorders and the commonest alternative psychiatric diagnosis was depressive illness. Altogether 184 of 377 (49%) patients had alternative diagnoses to CFS.

CONCLUSIONS: Half of all the referred patients to a specialist CFS clinic had alternative medical and psychiatric diagnoses. Specialist medical assessment for patients with unexplained, disabling, chronic fatigue needs to incorporate both medical and psychiatric assessments.

 

Source: Devasahayam A, Lawn T, Murphy M, White PD. Alternative diagnoses to chronic fatigue syndrome in referrals to a specialist service: service evaluation survey. JRSM Short Rep. 2012 Jan;3(1):4. doi: 10.1258/shorts.2011.011127. Epub 2012 Jan 12.https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3269106/ (Full article)

 

The comorbidity of self-reported chronic fatigue syndrome, post-traumatic stress disorder, and traumatic symptoms

Abstract:

BACKGROUND: Data from primary care and community samples suggest higher rates of post-traumatic stress disorder (PTSD) among individuals with chronic fatigue syndrome (CFS).

OBJECTIVE: This study investigated the co-occurrence of CFS, PTSD, and trauma symptoms and assessed the contribution of familial factors to the association of CFS with lifetime PTSD and current traumatic symptoms.

METHOD: Data on lifetime CFS and PTSD, as measured by self-report of a doctor’s diagnosis of the disorder, and standardized questionnaire data on traumatic symptoms, using the Impact of Events Scale (IES), were obtained from 8544 female and male twins from the community-based University of Washington Twin Registry.

RESULTS: Lifetime prevalence of CFS was 2% and lifetime prevalence of PTSD was 4%. Participants who reported a history of PTSD were over eight times more likely to report a history of CFS. Participants with scores ≥ 26 on the IES were over four times more likely to report CFS than those who had scores ≤ 25. These associations were attenuated but remained significant after adjusting for familial factors through within-twin pair analyses.

CONCLUSION: These results support similar findings that a lifetime diagnosis of CFS is strongly associated with both lifetime PTSD and current traumatic symptoms, although familial factors, such as shared genetic and environmental contributions, played a limited role in the relationship between CFS, PTSD, and traumatic symptoms. These findings suggest that future research should investigate both the familial and the unique environmental factors that may give rise to both CFS and PTSD.

Published by Elsevier Inc.

 

Source: Dansie EJ, Heppner P, Furberg H, Goldberg J, Buchwald D, Afari N. The comorbidity of self-reported chronic fatigue syndrome, post-traumatic stress disorder, and traumatic symptoms. Psychosomatics. 2012 May-Jun;53(3):250-7. doi: 10.1016/j.psym.2011.08.007. Epub 2012 Jan 31. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3343192/ (Full article)

 

Role of Lactobacillus acidophilus loaded floating beads in chronic fatigue syndrome: behavioral and biochemical evidences

Abstract:

BACKGROUND: In recent years the interface between neuropsychiatry and gastroenterology has converged in to a new discipline referred to as enteric neuroscience. Implications of brain-gut communication in the pathogenesis of psychiatric disorders indicate a possible role of suitably packaged/delivered probiotics as newer therapeutic options. In the present study probable role of per-oral administration of free Lactobacillus acidophilus (LAB) and LAB loaded alginate beads in attenuation of the symptoms associated with chronic fatigue syndrome (CFS) were evaluated.

METHODS: Chronic fatigue syndrome following physical fatigue was induced in rats by forcing them to swim (forced swim test; FST) in water till exhaustion, after weighing them down with 10% their body weight, daily for 28 days. Immobility (I) and postswim fatigue time (PSF) were taken as suitable markers. Free LAB and LAB loaded floating beads (FBs) were administered, from 21 to 28 days.

KEY RESULTS: Immobility and PSF were found to increase considerably in FST rats (665 ± 22 s and 196 ± 6 s) as compared with the naïve (32 ± 7 s and 22 ± 2 s) at 20 days, establishing severe fatigue like behavior. FST control group exhibited significant (P < 0.05) hypertrophy of spleen, hypotrophy of thymus, and increased oxido-nitrosative stress in brain and tumor necrosis factor-α (TNF-α) levels in serum. Treatment with LAB and LAB FBs significantly decreased I and PSF and attenuated (P < 0.05) oxido-nitrosative stress and TNF-α levels. Spleen and thymus were also restored to their original size in this group.

CONCLUSIONS & INFERENCES: The findings suggest a valuable therapeutic role of LAB especially when incorporated into alginate beads for the treatment of CFS.

© 2012 Blackwell Publishing Ltd.

 

Source: Singh PK, Chopra K, Kuhad A, Kaur IP. Role of Lactobacillus acidophilus loaded floating beads in chronic fatigue syndrome: behavioral and biochemical evidences. Neurogastroenterol Motil. 2012 Apr;24(4):366-e170. doi: 10.1111/j.1365-2982.2011.01861.x. Epub 2012 Feb 1. https://www.ncbi.nlm.nih.gov/pubmed/22296294

 

Increased ventricular lactate in chronic fatigue syndrome. III. Relationships to cortical glutathione and clinical symptoms implicate oxidative stress in disorder pathophysiology

Abstract:

Chronic fatigue syndrome (CFS) is a complex illness, which is often misdiagnosed as a psychiatric illness. In two previous reports, using (1)H MRSI, we found significantly higher levels of ventricular cerebrospinal fluid (CSF) lactate in patients with CFS relative to those with generalized anxiety disorder and healthy volunteers (HV), but not relative to those with major depressive disorder (MDD). In this third independent cross-sectional neuroimaging study, we investigated a pathophysiological model which postulated that elevations of CSF lactate in patients with CFS might be caused by increased oxidative stress, cerebral hypoperfusion and/or secondary mitochondrial dysfunction.

Fifteen patients with CFS, 15 with MDD and 13 HVs were studied using the following modalities: (i) (1)H MRSI to measure CSF lactate; (ii) single-voxel (1)H MRS to measure levels of cortical glutathione (GSH) as a marker of antioxidant capacity; (iii) arterial spin labeling (ASL) MRI to measure regional cerebral blood flow (rCBF); and (iv) (31)P MRSI to measure brain high-energy phosphates as objective indices of mitochondrial dysfunction.

We found elevated ventricular lactate and decreased GSH in patients with CFS and MDD relative to HVs. GSH did not differ significantly between the two patient groups. In addition, we found lower rCBF in the left anterior cingulate cortex and the right lingual gyrus in patients with CFS relative to HVs, but rCBF did not differ between those with CFS and MDD. We found no differences between the three groups in terms of any high-energy phosphate metabolites.

In exploratory correlation analyses, we found that levels of ventricular lactate and cortical GSH were inversely correlated, and significantly associated with several key indices of physical health and disability. Collectively, the results of this third independent study support a pathophysiological model of CFS in which increased oxidative stress may play a key role in CFS etiopathophysiology.

Copyright © 2012 John Wiley & Sons, Ltd.

 

Source: Shungu DC, Weiduschat N, Murrough JW, Mao X, Pillemer S, Dyke JP, Medow MS, Natelson BH, Stewart JM, Mathew SJ. Increased ventricular lactate in chronic fatigue syndrome. III. Relationships to cortical glutathione and clinical symptoms implicate oxidative stress in disorder pathophysiology. NMR Biomed. 2012 Sep;25(9):1073-87. doi: 10.1002/nbm.2772. Epub 2012 Jan 27. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3896084/ (Full article)

 

Validation of the three-factor model of the PSQI in a large sample of chronic fatigue syndrome (CFS) patients

Abstract:

OBJECTIVE: To evaluate whether a 3-factor model of the Pittsburgh Sleep Quality Index (PSQI) scale would fit the constellation of sleep disturbances in patients with a diagnosis of chronic fatigue syndrome (CFS).

METHODS: Consecutive CFS patients filled out the PSQI. Scores from this self-report questionnaire were examined with exploratory and confirmatory factor analysis (CFA).

RESULTS: 413 CFS patients were included for analysis in this study. CFA showed that the 7 PSQI component scores clustered into the 3 factors reported by Cole et al. (2006), i.e. Sleep Efficiency, Perceived Sleep Quality and Daily Disturbances. In contrast with the single-factor and all 2-factor models, all factor loadings were significant, and all goodness-of-fit values were acceptable.

CONCLUSION: In CFS, the PSQI operates as a 3-factor scoring model as initially seen in healthy and depressed older adults. The separation into 3 discrete factors suggests the limited usefulness of the global PSQI as a single factor for the assessment of subjective sleep quality, as also evidenced by a low Cronbach’s alpha (0.64) in this patient sample.

Copyright © 2011 Elsevier Inc. All rights reserved.

 

Source: Mariman A, Vogelaers D, Hanoulle I, Delesie L, Tobback E, Pevernagie D. Validation of the three-factor model of the PSQI in a large sample of chronic fatigue syndrome (CFS) patients. J Psychosom Res. 2012 Feb;72(2):111-3. doi: 10.1016/j.jpsychores.2011.11.004. Epub 2011 Dec 22. https://www.ncbi.nlm.nih.gov/pubmed/22281451

 

Chronic fatigue syndrome and impaired peripheral pulse characteristics on orthostasis–a new potential diagnostic biomarker

Abstract:

Autonomic nervous system dysfunction is frequently reported in chronic fatigue syndrome (CFS) with orthostatic intolerance, a common symptom that can be objectively assessed. The frequent finding of autonomic dysfunction and symptoms on standing has the potential to provide a diagnostic biomarker in chronic fatigue. In this study we explored the clinical value of non-invasive optical multi-site photoplethysmography (PPG) technology to assess cardiovascular responses to standing.

Multi-site PPG pulses were collected from tissue pads of the ears, fingers and toes of 14 patients with CFS and 14 age-matched sedentary subjects using a measurement protocol of a 10 min baseline (subject supine) followed by 3 min of tilting on a tilt table (head-up to 70°). Percentage change in pulse timing (pulse transit time, PTTf) and pulse amplitude (AMP) at each site were calculated using beat-to-beat pulse wave analysis.

A significant reduction in the overall pulse timing response to controlled standing was found for the CFS group (using summed absolute percentage change in PTTf for ear, finger and toe sites, median change of 26% for CFS and 37% for control with p = 0.002).

There were no significant differences between subject groups for the AMP measure at any site. Changes in AMP with tilt were, however, weakly significantly and negatively correlated with fatigue severity (p < 0.05). Receiver operating characteristic (ROC) analysis of timing measures produced an area under the curve of 0.81. Experimental linear discriminant classification analysis comparing both timing and amplitude measures produced an overall diagnostic accuracy of 82%.

Pulse wave abnormalities have been observed in CFS and represent a potential objective measure to help differentiate between CFS patients and healthy controls.

 

Source: Allen J, Murray A, Di Maria C, Newton JL. Chronic fatigue syndrome and impaired peripheral pulse characteristics on orthostasis–a new potential diagnostic biomarker. Physiol Meas. 2012 Feb;33(2):231-41. doi: 10.1088/0967-3334/33/2/231. Epub 2012 Jan 25. https://www.ncbi.nlm.nih.gov/pubmed/22273713

 

Psychophysical distress and alexithymic traits in chronic fatigue syndrome with and without comorbid depression

Abstract:

Patients with chronic fatigue syndrome (CFS) often report a comorbid depressive disorder. Comorbid depression may negatively influence the long-term outcome of CFS therefore it must be correctly diagnosed and treated. The aim of the present study is to provide a clinical and psychometric assessment of CFS patients with and without depressive features.

A comparative analysis between 57 CFS subjects (CDC, 1994), 17 of whom with a comorbid depression, and 55 matched healthy volunteers was assessed to evaluate the presence of any psychophysical distress and alexithymic traits, by means of Symptom Checklist-90-R (SCL-90R) and Toronto Alexithymia Scale (TAS-20). The severity of fatigue was also assessed in all CFS patients using the Fatigue Impact Scale (FIS). With regard to psychiatric comorbidity, the SCL-90R scores showed higher levels of somatic complaints in CFS patients than in healthy subjects, whereas augmented depressive and obsessive-compulsive symptoms were observed only in the depressed CFS subgroup.

When comparing the TAS-20 scores, we observed a selective impairment in the capacity to identify feelings and emotions, as measured by the Difficulty in Identifying Feelings subscale (DIF), non-depressed CFS patients showing an intermediate score between depressed CFS and healthy controls. Finally, in terms of FIS scores, a statistical trend versus a higher fatigue severity in depressed CFS patients, with respect to non-depressed ones, was observed. In conclusion, comorbid depression in CFS significantly increased the level of psychophysical distress and the severity of alexithymic traits. These findings suggest an urgent need to address and treat depressive disorders in the clinical care of CFS cases, to improve social functioning and quality of life in such patients.

 

Source: Sepede G, Racciatti D, Gorgoretti V, Nacci M, Pizzigallo E, Onofrj M, Di Giannantonio M, Niolu C, Salerno RM, Gambi F. Psychophysical distress and alexithymic traits in chronic fatigue syndrome with and without comorbid depression. Int J Immunopathol Pharmacol. 2011 Oct-Dec;24(4):1017-25. https://www.ncbi.nlm.nih.gov/pubmed/22230407