• Epstein-Barr virus: Epstein-Barr virus (EBV) is a member of the herpes group (which includes herpes simplex 1 and 2, varicella zoster, cytomegalovirus, and pseudorabies virus) that can maintain lifelong latent infection kept in check by functional im-munity. Immunocompromise permits viral replication and dissemination, as in AIDS, cancer, or drug-induced immunosuppression. Almost all human beings are exposed to EBV by early adulthood. Primary infection in childhood often is asymptomatic; but in adolescence or early adulthood mononucleosis • Other infectious agents under investigation: human herpes virus-6, Inoue-Melnick virus, Brucella, Borrelia burgdorferi, Giardia lamblia, cytomegalovirus, enterovirus, retrovirus. • Immune system abnormalities: elevated antibodies to viral proteins; decreased natural killer (NK) cell activity; low or elevated antibody levels; increased or decreased levels of circulating immune complexes; increased cytokines (e.g., interleukin-2); increased or decreased interferon; altered helper/suppressor T-cell ratio. No specific immunodysfunction pattern has been recognized, but the most consistent abnormality is decreased number or activity of NK cells. NK cells destroy cancerous or virus-infested cells. (CFS was at one time called low natural killer cell syndrome). Reduced lymphocyte response to stimuli is perhaps caused by reduced activity or production of interferon, found in most cases. Low interferon permits reactivation of latent viruses. High interferon and interleukin-1 may cause CFS symptoms from physiologic effects, as seen during interferon therapy for cancer and viral hepatitis. • Fibromyalgia and multiple chemical sensitivities: the only difference in diagnostic criteria for fibromyalgia (FM) and CFS is musculoskeletal pain in FM and fatigue in CFS. Diagnosis of FM or CFS depends on type of physician consulted. Approximately 70% of patients with FM and 30% with multiple chemical sensitivities (MCS) meet CDC criteria for CFS; 80% of both FM and MCS patients meet CFS criterion of fatigue for more than 6 months with 50% reduction in activity. More than 50% of CFS and FM patients have adverse reactions to various chemicals. • Other causes of CFS: preexisting physical condition (diabetes, heart disease, lung disease, rheumatoid arthritis, chronic inflammation, chronic pain, cancer, liver disease, multiple sclerosis), prescription drugs (antihypertensives, antiinflammatory agents, birth control pills, antihistamines, corticosteroids, tranquilizers, and sedatives), depression, stress/low adrenal function, impaired liver function and/or environmental illness, impaired immune function, chronic candidiasis, other chronic infections, food allergies, hypothyroidism, hypoglycemia, anemia and nutritional defi-ciencies, and sleep disturbances. • Identify as many factors as possible contributing to fatigue. • Complete physical examination: swollen lymph nodes (chronic infection), diagonal crease in both earlobes (impaired blood flow). • Lab: avoid expensive tests unless absolutely necessary. Complete blood count and chemistry panel (including serum ferritin for menstruating women). Avoid tests to confirm diagnosis that will not affect treatment. Assess thyroid function, liver detoxification function, bowel dysbiosis, and gastrointestinal permeability (Textbook, “Chronic Fatigue Syndrome,” “Comprehensive Stool Analysis 2.0,” and “Intestinal Permeability Assessment”). • Multifactorial conditions require tailored multiple therapies. • Energy level and emotional state: determined by internal focus and physiology. The mental focus of CFS is on fatigue. Physiology is affected by chemicals, hormones, posture, and breathing (shallow). Address mind and body. • Depression: a major cause of chronic fatigue and common in CFS. Depression is the most common cause of chronic fatigue in the absence of preexisting pathosis. • Stress: underlying factor in a patient with depression, low immune function, or other cause of chronic fatigue (Textbook, “Stress Management”). Evaluate stress effects with the Social Readjustment Rating Scale by Holmes and Rahe. • Impaired liver function and/or environmental illness: exposure to toxins (food additives, solvents [cleaning materials, formaldehyde, toluene, benzene, etc.], pesticides, herbicides, heavy metals [lead, mercury, cadmium, arsenic, nickel, and aluminum]) causes “congested” or “sluggish” liver and impaired hepatic detoxification, leading to diminished bile flow (cholestasis) and decreased phase I and/or phase II enzyme detoxification activity. Causes of cholestasis: dietary factors (saturated fat, refined sugar, low fiber intake), obesity, diabetes, gallstones, alcohol, endotoxins, hereditary disorders (Gilbert’s syndrome), pregnancy, steroid hormones (anabolic steroids, estrogens, oral contraceptives), chemicals (cleaning solvents, pesticides), or drugs (antibiotics, diuretics, nonsteroidal antiinflammatory drugs, thyroid hormone), viral hepatitis. • Clinical judgment and lab tests: serum bilirubin, aspartate aminotransferase, alanine aminotransferase, lactate dehydrogenase, glycoprotein 4-beta-galactosyl transferase, bile acid assay, clearance tests (Textbook, “Chronic Fatigue Syndrome”). Test results may be abnormal only after significant liver damage; many conditions in subclinical stages have normal lab values. Common patient symptoms: depression, general malaise, headaches, digestive disturbances, allergies and chemical sensitivities, premenstrual syndrome, constipation. Hair mineral analysis can screen for heavy metals; if inconclusive, use 8-hour lead mobilization test with chelating agent edetate calcium disodium, which measures lead excreted in urine for 8 hours after injection of EDTA. • Excessive gastrointestinal permeability: common finding in CFS, measured by lactulose/mannitol absorption test (Textbook, “Intestinal Permeability Assessment”). Use food allergy control and nutrients to stimulate gastrointestinal regeneration. Support hepatic phase I and II detoxification and use oligoantigenic rice protein food replacement formula. • Impaired immune function and/or chronic infection: fatigue is the body’s response to infection; the immune system works best when the body rests. Use immune function questionnaire on page 176, and lab tests in Textbook, “Immune Function Assessment. • Chronic Candida infection: impaired immunity allows Candida overgrowth in the intestines. Diagnosis is difficult; no single specific test exists. Stool cultures and elevated Candida antibody levels plus detailed history and patient questionnaire (Textbook, “Chronic Candidiasis”). • Patient profile: female, 15-50 years old, chronic fatigue, lack of energy, malaise, decreased libido, thrush, bloating, gas, intestinal cramps, rectal itching, altered bowel function, vaginal yeast infection, frequent bladder infections, menstrual symptoms, depression, irritability, inability to concentrate, allergies, chemical sensitivities, low immunity, craving for foods rich in carbohydrates or yeast. • History: chronic vaginal yeast infections, long-term antibiotic use for infections or acne, oral birth control use, oral steroid hormone use. • Associated conditions: premenstrual syndrome; sensitivity to foods, chemicals, and other allergens; endocrine disturbances; psoriasis; irritable bowel syndrome. • Predisposing factors: impaired immunity, antiulcer drugs, broad-spectrum antibiotics, cellular immunodeficiency, corticosteroids, diabetes mellitus, excess sugar intake, intravascular catheters, intravenous drug use, lack of digestive secretions, oral contraceptives.
Chronic Fatigue Syndrome
ETIOLOGY
DIAGNOSIS
THERAPEUTIC CONSIDERATIONS
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Chronic Fatigue Syndrome
