Case Study 1
49 year-old female was in good health until July 2003 when she developed a severe flu-like illness. The patient was living in Incline village, Lake Tahoe for 14 months. The patient had low-grade fever, chills, myalgia, severe throat swelling followed by neck pain, without sinus congestion, cough, chest pain, headache or diarrhea. Physical examination after one week of illness demonstrated neck tenderness. A complete blood count, comprehensive chemistry panel, thyroid function test and erythrocyte sedimentation rate were normal The patient was told to have either a viral infection or lupus. CT scan of the brain and spinal tap performed for the severe headache did not reveal any findings. Chest x-ray was negative. Treatment with Medrol dose pack and Celebrex did not alleviate her symptoms, except the neck pain improved to some extent. The symptoms of acute illness lasted about several weeks but the fatigue and neck pain never resolved. The patient subsequent had relapsing symptoms of fatigue, myalgia, low-grade fevers, night sweats, sore throat and cervical lymphadenopathy, cognitive dysfunction and debilitating headache. The patient received Medrol dose pack 4 different times since the beginning of the illness. The illness spontaneously cycled every week with one good day at an energy level of 6/10 and 1-3 bad days a week with energy level of 2-4/10. She could not concentrate and had severe post-exertional fatigue for 2-3 days. She had been depressed and crying a lot. The patient was only able to work 20 hours a week, but had severe fatigue after work requiring extra hours of sleep at night and on weekends to build up enough energy for work. She woke up quite often especially when she was more tired. The maximal exercise she can perform now is walking one block whereas she could swim and ski before he became ill. She would need to take a nap frequently. She has gained 20 lbs in one year. Afterwards, she had to quit her job due to increasing fatigue.
IgG antibody to Epstein-Barr virus and CMV were minimally elevated, but the IgM antibody was negative. C. pneumoniae IgG was 1:8. Antibody titers for coxsackievirus B1-6 and echoviruses 6,7,9,11,30 were not significantly elevated.
Physical examination: mild throat inflammation, minimal, tender anterior neck lymph nodes. Significant epigastric and right lower quadrant tenderness. Diffuse muscles tenderness
Laboratory investigation: low level of enteroviral RNA was detected in the whole blood. Staining of stomach biopsy showed extensive enteroviral protein (as shown, 100x magnification).
She tolerated the combination of alpha and gamma interferon poorly. Subsequently, she was treated with IVIG every 3 months with mild improvement.
Assessment & Treatment: Chronic fatigue syndrome � the patient's symptoms started in the summer of 2003 following a flu-like illness. The nature of the illness was highly suggestive of enteroviral infection. Incline village, the place where the infection was acquired had a major epidemic of CFS/ME in 1984, and the etiology was never elucidated by the CDC investigators. However, lake water is known to have enteroviruses. The patient has fulfilled the 2 major and 4 minor criteria for the diagnosis of CFS, as established by the CDC in 1994. The results of the serological study were not diagnostic for acute EBV, CMV or enterovirus infections. The major drawback of the serological testing is that neutralizing antibody tests are only available for 11 of 70+ non-polio enteroviruses. However, enterovirus RNA was detected in the blood and the staining of the stomach biopsies demonstrated extensive viral protein few years after the initial infection, consistent with chronic enterovirus infection . The use of medrol dose pack during the acute phase of infection most likely shifted the immune response to the Th2 (T helper 2) direction, which allow the viruses to persist in the body. She has mild to modest improvement with IVIG infusion given every 3 months.
49 year-old female was in good health until July 2003 when she developed a severe flu-like illness. The patient was living in Incline village, Lake Tahoe for 14 months. The patient had low-grade fever, chills, myalgia, severe throat swelling followed by neck pain, without sinus congestion, cough, chest pain, headache or diarrhea. Physical examination after one week of illness demonstrated neck tenderness. A complete blood count, comprehensive chemistry panel, thyroid function test and erythrocyte sedimentation rate were normal The patient was told to have either a viral infection or lupus. CT scan of the brain and spinal tap performed for the severe headache did not reveal any findings. Chest x-ray was negative. Treatment with Medrol dose pack and Celebrex did not alleviate her symptoms, except the neck pain improved to some extent. The symptoms of acute illness lasted about several weeks but the fatigue and neck pain never resolved. The patient subsequent had relapsing symptoms of fatigue, myalgia, low-grade fevers, night sweats, sore throat and cervical lymphadenopathy, cognitive dysfunction and debilitating headache. The patient received Medrol dose pack 4 different times since the beginning of the illness. The illness spontaneously cycled every week with one good day at an energy level of 6/10 and 1-3 bad days a week with energy level of 2-4/10. She could not concentrate and had severe post-exertional fatigue for 2-3 days. She had been depressed and crying a lot. The patient was only able to work 20 hours a week, but had severe fatigue after work requiring extra hours of sleep at night and on weekends to build up enough energy for work. She woke up quite often especially when she was more tired. The maximal exercise she can perform now is walking one block whereas she could swim and ski before he became ill. She would need to take a nap frequently. She has gained 20 lbs in one year. Afterwards, she had to quit her job due to increasing fatigue.
IgG antibody to Epstein-Barr virus and CMV were minimally elevated, but the IgM antibody was negative. C. pneumoniae IgG was 1:8. Antibody titers for coxsackievirus B1-6 and echoviruses 6,7,9,11,30 were not significantly elevated.
Physical examination: mild throat inflammation, minimal, tender anterior neck lymph nodes. Significant epigastric and right lower quadrant tenderness. Diffuse muscles tenderness
Laboratory investigation: low level of enteroviral RNA was detected in the whole blood. Staining of stomach biopsy showed extensive enteroviral protein (as shown, 100x magnification).
She tolerated the combination of alpha and gamma interferon poorly. Subsequently, she was treated with IVIG every 3 months with mild improvement.
Assessment & Treatment: Chronic fatigue syndrome � the patient's symptoms started in the summer of 2003 following a flu-like illness. The nature of the illness was highly suggestive of enteroviral infection. Incline village, the place where the infection was acquired had a major epidemic of CFS/ME in 1984, and the etiology was never elucidated by the CDC investigators. However, lake water is known to have enteroviruses. The patient has fulfilled the 2 major and 4 minor criteria for the diagnosis of CFS, as established by the CDC in 1994. The results of the serological study were not diagnostic for acute EBV, CMV or enterovirus infections. The major drawback of the serological testing is that neutralizing antibody tests are only available for 11 of 70+ non-polio enteroviruses. However, enterovirus RNA was detected in the blood and the staining of the stomach biopsies demonstrated extensive viral protein few years after the initial infection, consistent with chronic enterovirus infection . The use of medrol dose pack during the acute phase of infection most likely shifted the immune response to the Th2 (T helper 2) direction, which allow the viruses to persist in the body. She has mild to modest improvement with IVIG infusion given every 3 months.