Chronic fatigue syndrome

Abstract:

Reports on conditions of chronic fatigue associated with other somatopsychic symptoms after acute viral infections have led to the hypothesis of a “chronic fatigue syndrome” (CFS). Historical disease descriptions, like e.g. “myalgic encephalomyelitits”, were updated by means of modern virological diagnostic techniques and data analysis.

Several viral agents like enteroviruses, Epstein-Barr virus, Human-Herpesvirus 6 and other herpesviruses have been implicated for possible underlying infections. A preliminary disease definition by the Center for Disease Control (CDC) seeks to provide a rational basis for further etiological studies. In fact, there is growing consensus that the syndrome comprises various separate disease entities and causative agents.

Today we can tentatively differentiate a “chronic mononucleosis” after infection with Epstein-Barr virus, an etiologically undetermined “postviral fatigue syndrome” and a fatigue syndrome of the myalgic type after Coxsackie-B virus infection. Furthermore, a valid diagnosis of CFS must be based on the exclusion of defined other diseases and the awareness of dealing with a hypothetical concept. As a result, current knowledge does not yet allow specific therapeutic recommendations.

 

Source: Ewig S, Dengler HJ. Chronic fatigue syndrome. Klin Wochenschr. 1990 Aug 17;68(16):789-96. [Article in German] http://www.ncbi.nlm.nih.gov/pubmed/2170741

 

Myalgic encephalomyelitis: an alternative theory

Note: in this editorial published in the Journal of the Royal Society of Medicine ,Volume 83, August 1990, Dr. Wilson discusses the role allergy plays in the development of post-viral fatigue syndromes.

 

In his discussion paper on myalgic encephalomyelitis (April 1989 JRSM, p 215), Wessley drew attention to the destruction of body and mind, and subsequent suicidal despair, and torment, of patients suffering from myalgic encephalomyelitis (ME) or the postviral fatigue syndrome (PVFS). He referred to the reported relationship between identification of the VPI antigen and the presence of disease symptoms. He stated that more attention requires to be paid to methodological detail which he defined as population sample definition, and adoption of operational criteria. He suggested that a new term should be used to describe the observed symptoms: chronic fatigue syndrome (CFS), and enquired what constitutes the syndrome? Unfortunately he did not refer to the necessity for taking a complete clinical and family history in all patients. In his definition of CFS, he did not refer to any of the somatic symptoms which are always present. Yet, he stated that cases of this disease can only be selected by the (presumably holistic) clinical history. It appears that a new kind of approach based on absence of prejudice, more exhaustive and thorough clinical history taking, a wider approach to clinical examination of the patients, and a critical assessment of the origin of this psychosomatic disease would be of value in our investigations.

You can read the rest of the article here: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1292769/pdf/jrsocmed00133-0005b.pdf

 

Source: Wilson CW. Myalgic encephalomyelitis: an alternative theory. J R Soc Med. 1990 Aug;83(8):481-483. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1292769/

 

Chronic fatigue. A prospective clinical and virologic study

Abstract:

To evaluate the clinical and virologic course of patients with chronic fatigue who had elevated Epstein-Barr virus (EBV) titers, we prospectively followed up 26 patients with serial cultures for EBV in blood and saliva and serial EBV serologic and clinical and psychiatric evaluations, and we compared these results with those for healthy controls.

The frequency of isolating EBV in blood or demonstrating EBV infection by in situ hybridization in blood lymphocytes or in saliva was similar in patients and controls. The prevalence and titers of antibody to human herpesvirus type 6 were also similar in the two populations. Patients with chronic fatigue did demonstrate higher in vitro natural killer activity and lower in vitro interleukin 2 production than controls, and patients had a high frequency of DSM-III depressive illness. Over 50% of patients with chronic fatigue improved over the course of follow-up. Improvement was not associated with any discernible change in titers of EBV proteins.

No evidence of ongoing EBV infection with either transforming or nontransforming strains was demonstrated in this population of patients with chronic fatigue. Clinically, most patients gradually improve over time.

 

Source: Gold D, Bowden R, Sixbey J, Riggs R, Katon WJ, Ashley R, Obrigewitch RM, Corey L. Chronic fatigue. A prospective clinical and virologic study. JAMA. 1990 Jul 4;264(1):48-53. http://www.ncbi.nlm.nih.gov/pubmed/2162397

 

Postviral syndrome

Note: This letter appeared in the Journal of the Royal Society of Medicine, Volume 83, July 1990.

 

We read with interest the paper by Bowman (December 1989 JRSM, p 712) which suggests that the positive monospot test may only be present within the first four weeks of the illness. They also questioned the specificity of V P-I antigen, a view recently supported by Lynch and Seth. (1)

We are, however, interested in their comment that the General Health Questionnaire (GHQ) is having a limited usefulness in the context, of postviral syndrome. They have used an older version of the GHQ which includes 60 questions. There is a 30 item GHQ which was derived from the GHQ-60 by excluding symptoms that were commonly present in subjects with entirely physical illness thus the GHQ-30 could be regarded as a measure of more purely psychological or psychosocial symptoms (2). Another difficulty with postviral syndrome patients is that by definition they suffer from chronic symptoms. By using the GHQ as a screening instrument, it is likely that there will be a number of cases that will not be detected by GHQ (false negatives). It has been suggested that false negatives largely result from the relative insensitivity of the GHQ for chronic disorders (3,4). To overcome this problem Goodchild and Duncan-Jones have proposed a new scoring procedure (C-GHQ) to eliminate the insensitivity of the GHQ for chronic complaints (5).

Further investigation on this showed that the new scoring method was better with regard to both the GHQ at the measure of severity and GHQ with the screening instrument (6,7). We therefore suggest that in future investigation of the psychological well being of patients with postviral syndrome the shorter version of the GHQ with the revised scoring methods is to be used.

~B T FARID Consultant Psychiatrist

~A CHANDRA Registrar in Psychiatry New Cross Hospital Wolverhampton WV10 0QP

References

1 Lynch S, Seth R. Postviral fatigue syndrome and the V P-I antigen. Lancet 1989;ii.1160-1

2 Huppert FA, et al. The factor structure of the General Health Questionnaire (GHQ-30). Br J Psychiatry 1989; 155:178-85

3 BenJamin S, elm P, Haran D. Community screening for mental illness: A validity study of the General Health Questionnaire. Br J Psychiatry 1982;140:174-80

4 Finlay-Jones RA, Murphy E. Severity of psychiatric disorder and the 30-item GHQ. Br J Psychiatry 1979; 134:609-16

5 Goodchild ME, Duncan-Jones P. Chronicity and the General Health Questionnaire. Br J Psychiatry 1985; 146:55-62

6 Koetar MWJ, Van Den Brink W, Ormel J. Chronic psychiatric complaints and the General Health Questionnaire. Br J Psychiary 1989;155:186-90.

7 Surtees PG. Psychiatric disorder in the community and the General Health Questionnaire. Br J Psychiatry 1987;150:828-35

 

Source:  B T Farid and A Chandra. Postviral syndrome. J R Soc Med. 1990 Jul; 83(7): 476. PMCID: PMC1292747 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1292747/

 

The chronic fatigue syndrome: a return to common sense

The chronic fatigue syndrome has become one of the past decade’s causes celebres, vying with ecological issues for a place in the public perception of real and imagined threats to society and the individual. Perhaps this interest is a manifestation of the malaise of fin de siecle which in other ages has led to outbursts of anarchy’ or increased eschatological preoccupation. Fortunately, the passing of time-and the cathartic benefits of publication have restored a more reasoned view of chronic fatigue and its attendant problems. Chronic fatigue first became prominent as one of the features of myalgic encephalomyelitis or the ‘ME syndrome’ and has subsequently been the subject of intense debate. (2’5) In truth, fatigue is a symptom with many causes and is thus comparable with dyspnoea or dyspepsia. However, in some patients it is the dominant complaint, thereby defining chronic fatigue as a syndrome sui generis in the minds of some observers.

You can read the rest of this article here: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2429649/pdf/postmedj00163-0004.pdf

 

Source: Denman AM. The chronic fatigue syndrome: a return to common sense. Postgrad Med J. 1990 Jul;66(777):499-501. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2429649/

 

Post-viral fatigue syndrome, viral infections in atopic eczema, and essential fatty acids

Abstract:

Three clinical observations relating to viral infections are well-known but poorly understood. These are: the susceptibility of people with atopic eczema to viral infections; the occasional precipitation of an atopic syndrome by viral infections; the occurrence of a fatigue syndrome following viral infections.

A unifying hypothesis is presented which explains these observations in terms of the interactions between viral infections and essential fatty acid (EFA) metabolism. Key elements of the hypothesis are the facts that interferon requires 6-desaturated EFAs in order to exert its anti-viral effects, that people with atopic eczema have low levels of 6-desaturated EFAs, and that viruses, as part of their attack strategy, may reduce the ability of cells to make 6-desaturated EFAs.

The hypothesis has practical implications for the treatment of patients with viral infections.

 

Source: Horrobin DF. Post-viral fatigue syndrome, viral infections in atopic eczema, and essential fatty acids.  Med Hypotheses. 1990 Jul;32(3):211-7.  http://www.ncbi.nlm.nih.gov/pubmed/2204789

 

Chronic fatigue syndrome–a new disease picture?

Abstract:

The chronic fatigue syndrome has recently been more frequently diagnosed. Yet it is unknown if this syndrome represents a disease entity of its own or merely a diagnostic label for a miscellaneous group of disorders. Further investigations are needed to find out if the syndrome has an organic or psychosomatic aetiology, or a mixture of both. In the meantime it is the responsibility of the clinician to make this decision in each individual case.

 

Source:  Nix WA. Chronic fatigue syndrome–a new disease picture? Nervenarzt. 1990 Jul;61(7):390-6. [Article in German] http://www.ncbi.nlm.nih.gov/pubmed/2202912

 

Myalgic encephalomyelitis–a persistent enteroviral infection?

Abstract:

Myalgic encephalomyelitis is a common disability but frequently misinterpreted. Amongst 6,000 patients referred for general microbiological diagnosis between 1975 and 1987, 420 cases were recognized.

Coxsackie B neutralization tests, in 205 of these, demonstrated significant titres in 103/205 (50%), while of 124 additionally investigated for enteroviral IgM, 38/124 (31%) were positive. This illness is distinguished from a variety of other post-viral states by an unique clinical and epidemiological pattern characteristic of enteroviral infection.

Prompt recognition and advice to avoid over-exertion is mandatory. Routine diagnosis, specific therapy and prevention, await further technical advances.

 

Source:  Dowsett EG, Ramsay AM, McCartney RA, Bell EJ. Myalgic encephalomyelitis–a persistent enteroviral infection? Postgrad Med J. 1990 Jul;66(777):526-30. http://www.ncbi.nlm.nih.gov/pubmed/2170962

Note: You can read the full article here: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2429637/

 

The diagnosis of postviral syndrome

Note: This comment appeared in Journal of the Royal Society of Medicine Volume 83 June 1990. You can view the table referenced in the comment here: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1292703/pdf/jrsocmed00135-0083a.pdf

 

The difficulty of making a definitive diagnosis of postviral syndrome (myalgic encephalomyelitis) is emphasized by Dr Bowman and his colleagues (December 1988 JRSM, p 712).

After a patient with this condition reported benefit from hyperbaric oxygen (HBO) (1), 36 other patients requested to be treated at Centres administered by ‘Action and Research for Multiple Sclerosis’ (ARMS). Thirty had been investigated in hospital.

They received 20 daily one hour sessions breathing 100% oxygen under pressure. Thirteen patients reported symptomatic improvement at 1.25 atmospheres absolute (ata), 10 responded at 1.5 ata, three at 1.75 ata and two at 2.0 ata.

The patients were asked to record any changes in their symptoms at the end of the course and their accumulated replies are given in Table 1.

A speculative explanation is that high concentrations of oxygen may limit the excessive intracellular lactic acid in skeletal muscle that has been demonstrated in this disease(2). The clinical pattern of myalgic encephalomyelitis has much in common with multiple sclerosis and it is possible that some of these patients had, in fact, got MS.

However, muscle pains are seldom a feature of MS, while they occurred in all but four of these patients. Seventeen out of the 33 with this symptom reported improvement, a response to HBO which might be elaborated into a therapeutic test.

ARMS treated these patients (with the consent of their doctors) on an empirical basis, and it is not implied that HBO is a definitive treatment for ME. However, these reports of subjective improvement suggest that a formal trial should be initiated.

~D J D PERRINS Adviser on Hyperbaric Medicine to ARMS, 4a Chapel Hill, Stansted, Essex CM24 8AG

 References

1 Newsletter of the M.E. Association No 21, 1986

2 Arnold DL, Bore PJ, Radda GK, et al. Excessive intracellular acidosis of skeletal muscle on exercise in a patient with a post-viral exhaustion/fatigue syndrome. Lancet 1984;i:1367-9

 

Source: D J Perrins. The diagnosis of postviral syndrome.  J R Soc Med. 1990 Jun; 83(6): 413. PMCID: PMC1292703  http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1292703/

 

Immunologic abnormalities in chronic fatigue syndrome

Abstract:

The chronic fatigue syndrome (CFS), formerly known as chronic Epstein-Barr virus syndrome, is a clinical state of some complexity and uncertain etiology. In order to characterize in a comprehensive manner the status of laboratory markers associated with cellular immune function in patients with this syndrome, 30 patients with clinically defined CFS were studied.

All of the subjects were found to have multiple abnormalities in these markers. The most consistent immunological abnormality detected among these patients, when compared with normal controls, was low natural killer (NK) cell cytotoxicity. The number of NK cells, as defined by reactivity with monoclonal antibody NKH.1 (CD56), was elevated, but the killing of K562 tumor cells per CD56 cell was significantly diminished.

Lymphoproliferative responses after stimulation with phytohemagglutinin and pokeweed mitogen were decreased in most patients when compared with those in normal controls, as was the production of gamma interferon following mitogen stimulation. Lymphocyte phenotypic marker analysis of peripheral blood lymphocytes showed that there were significant differences between patients with CFS and controls.

There was an increase in the percentage of suppressor-cytotoxic T lymphocytes, CD8, and a proportionally larger increase in the number of CD8 cells expressing the class II activation marker. Most patients had an elevated number of CD2 cells which expressed the activation marker CDw26. The numbers of CD4 cells and the helper subset of CD4+CD29+ cells in patients with CFS were not different from those in controls. There was, however, a significant decrease in the suppressor inducer subset of CD4+ CD45RA+ cells. The number of B cells, CD20 and CD21, were elevated, as were the numbers of a subset of B cells which coexpressed CD20 and CD5.

The patterns of immune marker abnormalities observed was compatible with a chronic viral reactivation syndrome.

 

Source: Klimas NG, Salvato FR, Morgan R, Fletcher MA. Immunologic abnormalities in chronic fatigue syndrome. J Clin Microbiol. 1990 Jun;28(6):1403-10. http://www.ncbi.nlm.nih.gov/pubmed/2166084

Note: You can read the full article here: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC267940/