Chronic fatigue syndrome: a risk factor for osteopenia?

Abstract:

No data documenting a possible depletion of bone mineral density in patients with chronic fatigue syndrome (CFS) are currently available. However, recent pathophysiological observations in CFS patients may have deleterious consequences on bone density.

Firstly, the deregulation of the 2,5A synthetase RNase L antiviral pathway and its associated channelopathy, implicates increased demands for calcium and consequent increased calcium-re-absorption from the skeletal system.

Secondly, Mycoplasma fermentans which has been frequently associated with CFS, produces a lipopeptide, named 2-kDa macrophage-activating lipopeptide (MALP-2), which stimulates macrophages. MALP-2 has been shown to enhance bone resorption in a dose-dependent manner, at least in part by stimulating the formation of prostaglandins.

Thirdly, decreased levels of insulin-like growth factor I (IGF-I) have been reported in CFS-patients. IGF-I is critical to the proliferation of osteoblasts. Consequently, depleted levels of IGF-I may shift the balance between osteoclastic and osteoblastic activity towards bone resorption.

 

Source: Nijs J, De Meirleir K, Englebienne P, McGregor N. Chronic fatigue syndrome: a risk factor for osteopenia? Med Hypotheses. 2003 Jan;60(1):65-8. http://www.ncbi.nlm.nih.gov/pubmed/12450768

 

The report of the Chief Medical Officer’s CFS/ME working group: what does it say and will it help?

Abstract:

Chronic fatigue syndrome (CFS) sometimes known as myalgic encephalomyelitis or encephalopathy (ME) has long been a controversial topic. This year has seen the publication of a report from an independent working party set up by the UK Chief Medical Officer (CMO) to make recommendations for the management of the condition. The report makes a number of general recommendations about the provision of appropriate care and services. The more controversial issues of what to call the illness, the nature of the illness and what treatment should be recommended are all addressed, but in the form of compromise rather than resolution. To the extent that this report is a step towards highlighting the needs not only of patients with CFS but the larger group of patients with symptom-defined conditions, it is to be welcomed. As a guide to management it raises as many questions as it answers. Much remains to be resolved before guidance that is both evidence based and acceptable to all parties is achieved.

Comment in: Medically unexplained symptoms. [Clin Med (Lond). 2002]

 

Source: Sharpe M. The report of the Chief Medical Officer’s CFS/ME working group: what does it say and will it help? Clin Med (Lond). 2002 Sep-Oct;2(5):427-9. http://www.ncbi.nlm.nih.gov/pubmed/12448589

 

A tender sinus does not always mean rhinosinusitis

Abstract:

BACKGROUND: Sinus tenderness has not been quantitatively assessed.

OBJECTIVE: We sought to compare sinus and systemic tenderness in rhinosinusitis, allergic rhinitis, and chronic fatigue syndrome (CFS), and healthy (non-CFS) groups.

METHODS: Cutaneous pressures (kg/cm(2)) causing pain at 5 sinus and 18 systemic sites were measured in acute and chronic rhinosinusitis, active allergic rhinitis, healthy non-CFS/no rhinosinusitis, and CFS subjects.

RESULTS: Sinus thresholds differed significantly (P </= 10(-11), ANOVA) between non-CFS/no rhinosinusitis (1.59 +/- 0.14 kg/cm(2), mean +/- 95% CI, n = 117), allergic rhinitis (1.19 +/- 0.31, n = 30), exacerbations of chronic rhinosinusitis (1.25 +/- 0.26, n = 25), non-CFS/chronic rhinosinusitis (1.23 +/- 0.27, n = 23), acute rhinosinusitis (1.10 +/- 0.20, n = 22), CFS/no rhinosinusitis (0.98 +/- 0.15, n = 70), and CFS/chronic rhinosinusitis (0.78 +/- 0.12, n = 56). Systemic pressure thresholds were lower for CFS (1.46 +/- 0.15) than for non-CFS (2.67 +/- 0.22, P </= 10(-11)).

CONCLUSIONS: The lower sinus thresholds of rhinosinusitis groups validated the sign of sinus tenderness. Sinus and systemic thresholds were both 44% lower in CFS than in non-CFS subjects, suggesting that systemic hyperalgesia contributed to CFS sinus tenderness and “rhinosinusitis” complaints.

 

Source: Naranch K, Park YJ, Repka-Ramirez MS, Velarde A, Clauw D, Baraniuk JN. A tender sinus does not always mean rhinosinusitis. Otolaryngol Head Neck Surg. 2002 Nov;127(5):387-97. http://www.ncbi.nlm.nih.gov/pubmed/12447232

 

Unconscious amygdalar fear conditioning in a subset of chronic fatigue syndrome patients

Abstract:

Here, a novel hypothesis for chronic fatigue syndrome (CFS) is proposed. CFS may be a neurophysiological disorder focussing on the amygdala. During a ‘traumatic’ neurological event often involving acute psychological stress combined with a viral infection or other chemical or physiological stressor, a conditioned network or ‘cell assembly’ may be created in the amygdala. The unconscious amygdala may become conditioned to be chronically sensitised to negative symptoms arising from the body. Negative signals from the viscera or physiological, chemical and dietary stressors, become conditioned stimuli and the conditioned response is a chronic sympathetic outpouring from the amygdala via various brain pathways including the hypothalamus.

This cell assembly then produces the CFS vicious circle, where an unconscious negative reaction to symptoms causes immune reactivation/dysfunction, chronic sympathetic stimulation, leading to sympathetic dysfunction, mental and physical exhaustion, and a host of other distressing symptoms and secondary complications. And these are exactly the symptoms that the amygdala and associated limbic structures are trained to monitor and respond to, perpetuating a vicious circle. Recovery from CFS may involve projections from the medial prefrontal cortex to the amygdala, to control the amygdala’s expressions. I shall firstly discuss predisposing, precipitating, and perpetuating factors involved in the possible etiology of chronic fatigue syndrome (CFS), followed by the patient’s experience of the illness. Finally, I shall look at a suggested explanation for the symptoms of CFS.

Copyright 2002 Elsevier Science Ltd.

 

Source: Gupta A. Unconscious amygdalar fear conditioning in a subset of chronic fatigue syndrome patients. Med Hypotheses. 2002 Dec;59(6):727-35. http://www.ncbi.nlm.nih.gov/pubmed/12445517

The prognosis after multidisciplinary treatment for patients with postinfectious chronic fatigue syndrome and noninfectious chronic fatigue syndrome

Abstract:

The prognosis after multidisciplinary treatment for patients with postinfectious chronic fatigue syndrome (CFS, n = 9) and noninfectious CFS (n = 9) was clarified. After treatment, natural killer (NK) cell activity increased in the postinfectious CFS group but did not recover to within normal range in the noninfectious CFS group. In the postinfectious CFS group, physical and mental symptoms improved, and 8 patients returned to work. In the noninfectious CFS group, symptoms did not improve, and only 3 patients returned to work. The prognosis of postinfectious CFS group was better than that of noninfectious CFS group. Classification of CFS patients into postinfectious and noninfectious groups is useful for choosing the appropriate treatment in order to obtain better prognosis.

 

Source: Masuda A, Nakayama T, Yamanaka T, Koga Y, Tei C. The prognosis after multidisciplinary treatment for patients with postinfectious chronic fatigue syndrome and noninfectious chronic fatigue syndrome. J Behav Med. 2002 Oct;25(5):487-97. http://www.ncbi.nlm.nih.gov/pubmed/12442563

 

Women experienced chronic fatigue syndrome and fibromyalgia as stigmatising

Comment on: Women’s experiences of stigma in relation to chronic fatigue syndrome and fibromyalgia. [Qual Health Res. 2002]

 

Any clinician who has taken the trouble to get to know a patient with fibromyalgia or CFS will recognise the basic finding of the study by Åsbring and Närvänen — patients attending specialist clinics with either condition (the similarities between the 2 outweigh the differences) feel acutely a sense of discrimination and stigmatisation. Many describe negative interactions with the medical profession.1 This is most acute when doctors are perceived to be “psychologising” the condition. Indeed, patients in this study found the act of prescribing antidepressants to be “violating”. This is regrettable because evidence exists that antidepressants can reduce pain, fatigue, and sleep disturbances in patients with fibromyalgia,2 although similar evidence does not exist for patients with CFS.

You can read the rest of this comment here: http://ebmh.bmj.com/content/5/4/127.long

 

Source: Wessely S. Women experienced chronic fatigue syndrome and fibromyalgia as stigmatising. Evid Based Ment Health. 2002 Nov;5(4):127. http://ebmh.bmj.com/content/5/4/127.long (Full comment)

 

Systematic review of mental health interventions for patients with common somatic symptoms: can research evidence from secondary care be extrapolated to primary care?

Abstract:

OBJECTIVES: To determine the strength of evidence for the effectiveness of mental health interventions for patients with three common somatic conditions (chronic fatigue syndrome, irritable bowel syndrome, and chronic back pain). To assess whether results obtained in secondary care can be extrapolated to primary care and suggest how future trials should be designed to provide more rigorous evidence.

DESIGN: Systematic review.

DATA SOURCES: Five electronic databases, key texts, references in the articles identified, and citations from expert clinicians.

STUDY SELECTION: Randomised controlled trials including participants with one of the three conditions for which no physical cause could be found. Two reviewers screened sources and independently extracted data and assessed quality.

RESULTS: Sixty one studies were identified; 20 were classified as primary care and 41 as secondary care. For some interventions, such as brief psychodynamic interpersonal therapy, little research was identified. However, results of meta-analyses and of randomised controlled trials suggest that cognitive behaviour therapy and behaviour therapy are effective for chronic back pain and chronic fatigue syndrome and that antidepressants are effective for irritable bowel syndrome. Cognitive behaviour therapy and behaviour therapy were effective in both primary and secondary care in patients with back pain, although the evidence is more consistent and the effect size larger for secondary care. Antidepressants seem effective in irritable bowel syndrome in both settings but ineffective in chronic fatigue syndrome.

CONCLUSIONS: Treatment seems to be more effective in patients in secondary care than in primary care. This may be because secondary care patients have more severe disease, they receive a different treatment regimen, or the intervention is more closely supervised. However, conclusions of effectiveness should be considered in the light of the methodological weaknesses of the studies. Large pragmatic trials are needed of interventions delivered in primary care by appropriately trained primary care staff.

Comment in: Review: cognitive behavioural interventions may be effective for chronic fatigue syndrome and chronic back pain. [Evid Based Ment Health. 2003]

 

Source: Raine R, Haines A, Sensky T, Hutchings A, Larkin K, Black N. Systematic review of mental health interventions for patients with common somatic symptoms: can research evidence from secondary care be extrapolated to primary care? BMJ. 2002 Nov 9;325(7372):1082. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC131187/ (Full article)

 

High prevalence of Mycoplasma infections among European chronic fatigue syndrome patients. Examination of four Mycoplasma species in blood of chronic fatigue syndrome patients

Abstract:

Prevalence of Mycoplasma species infections in chronic fatigue syndrome (CFS) has been extensively reported in the scientific literature. However, all previous reports highlighted the presence of Mycoplasmas in American patients. In this prospective study, the presence of Mycoplasma fermentans, M. penetrans, M. pneumoniae and M. hominis in the blood of 261 European CFS patients and 36 healthy volunteers was examined using forensic polymerase chain reaction.

One hundred and seventy-nine (68.6%) patients were infected by at least one species of Mycoplasma, compared to two out of 36 (5.6%) in the control sample (P<0.001). Among Mycoplasma-infected patients, M. hominis was the most frequently observed infection (n=96; 36.8% of the overall sample), followed by M. pneumoniae and M. fermentans infections (equal frequencies; n=67; 25.7%). M. penetrans infections were not found. Multiple mycoplasmal infections were detected in 45 patients (17.2%). Compared to American CFS patients (M. pneumoniae>M. hominis>M. penetrans), a slightly different pattern of mycoplasmal infections was found in European CFS patients (M. hominis>M. pneumoniae, M. fermentansz.Gt;M. penetrans).

 

Source: Nijs J, Nicolson GL, De Becker P, Coomans D, De Meirleir K. High prevalence of Mycoplasma infections among European chronic fatigue syndrome patients. Examination of four Mycoplasma species in blood of chronic fatigue syndrome patients. FEMS Immunol Med Microbiol. 2002 Nov 15;34(3):209-14. http://femsim.oxfordjournals.org/content/34/3/209.long (Full article)

 

Therapy of circadian rhythm disorders in chronic fatigue syndrome: no symptomatic improvement with melatonin or phototherapy

Abstract:

BACKGROUND: Patients with chronic fatigue syndrome (CFS) show evidence of circadian rhythm disturbances. We aimed to determine whether CFS symptoms were alleviated by melatonin and bright-light phototherapy, which have been shown to improve circadian rhythm disorders and fatigue in jet-lag and shift workers.

DESIGN: Thirty patients with unexplained fatigue for > 6 months were initially assessed using placebo and then received melatonin (5 mg in the evening) and phototherapy (2500 Lux for 1 h in the morning), each for 12 weeks in random order separated by a washout period. Principal symptoms of CFS were measured by visual analogue scales, the Shortform (SF-36) Health Survey, Mental Fatigue Inventory and Hospital Anxiety and Depression Scale. We also determined the circadian rhythm of body temperature, timing of the onset of melatonin secretion, and the relationship between these.

RESULTS: Neither intervention showed any significant effect on any of the principal symptoms or on general measures of physical or mental health. Compared with placebo, neither body temperature rhythm nor onset of melatonin secretion was significantly altered by either treatment, except for a slight advance of temperature phase (0.8 h; P = 0.04) with phototherapy.

CONCLUSION: Melatonin and bright-light phototherapy appear ineffective in CFS. Both treatments are being prescribed for CFS sufferers by medical and alternative practitioners. Their unregulated use should be prohibited unless, or until, clear benefits are convincingly demonstrated.

 

Source: Williams G, Waterhouse J, Mugarza J, Minors D, Hayden K. Therapy of circadian rhythm disorders in chronic fatigue syndrome: no symptomatic improvement with melatonin or phototherapy. Eur J Clin Invest. 2002 Nov;32(11):831-7. http://www.ncbi.nlm.nih.gov/pubmed/12423324

 

Fatigue in chronic migraine patients

Abstract:

Fatigue is a common symptom frequently reported in many disorders including headaches, but little is known about its nature. The objective was to determine the prevalence of fatigue in chronic migraine (CM) patients, to define its subtypes and its relationship with other conditions comorbid with CM. Sixty-three CM patients were analysed. The Fatigue Severity Scale (FSS), the Chalder fatigue scale and the CDC diagnostic criteria for chronic fatigue syndrome (CFS) were used. Fifty-three (84.1%) patients had FSS scores greater than 27. Forty-two (66.7%) patients met the CDC criteria for CFS. Thirty-two patients (50.8%) met the modified CDC criteria (without headache). Beck depression scores correlated with FSS, mental and physical fatigue scores. Trait anxiety scores also correlated with fatigue scales. Women had higher FSS scores than men, P < 0.05. Physical fatigue was associated with fibromyalgia, P < 0.05. Fatigue as a symptom and CFS as a disorder are both common in CM patients. Therapeutic interventions include a graded aerobic exercise program, cognitive behavioural therapy and antidepressants. Identification of fatigue and its subtypes in headache disorders and recognition of headaches in CFS patients has implications for the pathophysiology, diagnosis and treatment of these disorders.

 

Source: Peres MF, Zukerman E, Young WB, Silberstein SD. Fatigue in chronic migraine patients. Cephalalgia. 2002 Nov;22(9):720-4. http://www.ncbi.nlm.nih.gov/pubmed/12421157