Case Study 3
15-year-old white male had recurrent upper respiratory tract infection since early childhood. The patient developed asthma and was treated with steroids at least 3 or 4 times over the years. He was able to play soccer but would have at least a brief relapse with symptoms of coughing, sore throat and fatigue for 7-10 days after playing in a tournament.
He was functional until September 2007 when he had bedridden fatigue, global headache, sore throat, insomnia, sinus congestion and persistent cough after another episode of respiratory infections. The symptoms did not respond to antibiotics or Elavil.
The results of EBV and CMV antibodies were consistent with prior infection. DNA test for CMV and EBV and Lyme's disease antibody were negative. Thyroid function tests, CBC, chemistry panel were all normal or negative. The patient was evaluated by other physicians who all concluded that the patient had a diagnosis of pediatric chronic fatigue syndrome and subclass IgG deficiency. Immunologic workup by an immunologist showed a B-cell dysfunction in that there is deficient memory for immunoglobulin production. Immunization with pneumococcus vaccine and HIB showed a positive antibody response which declined at six months. He actually was started on IVIG but had a reaction to the specific preparation of IVIG. The patient was treated with numerous antibiotics Biaxin, Augmentin, Cipro and Zithromax but experienced questionable improvement. Sinus CT scan showed extensive inflammatory changes but no air-fluid level. Previous cultures of sinus drainage have all been negative. Intravenous antibiotics did not help his symptoms.
The patient also had upper stomach pain, nausea, fullness after eating, diarrhea at least one time per week. He underwent a colonoscopy and EGD with biopsy on February 14, 2007. Multiple biopsies of the esophagus, stomach, duodenum, terminal ileum and various parts of the colon showed minimal inflammation but with prominent lymphoid aggregates in practically every biopsy. The patient has not been able to attend school and could not participate in competitive soccer and is basically homebound. He continues to have all the above symptoms of headache, bedridden fatigue, mild myalgia.
Laboratory studies showed Coxsackie B-4 antibody of 1:160, echovirus antibodies were negative. CMV IgG, IgM are now negative. IgG subclass-3 is still low at 32. HHV-6 antibody was 1:160.
PHYSICAL EXAMINATION: Sinuses - mildly tender. Throat mildly inflamed without ulceration, thrush. Neck � minimal lymph nodes. Abdomen - mild epigastric and right lower quadrant tenderness. There is minimal muscle tenderness over the upper and lower extremities. Neurological - looks somewhat tired but otherwise normal.
ASSESSMENT & TREATMENT: Chronic fatigue syndrome in a pediatric patient with B-cell dysfunction, low IgG1, IgG3 levels. The patient had frequent respiratory infections since childhood complicated by asthma. The patient likely has a Th2-dominant response which could not eradicate viruses that become persistent in his body. Instead of having numerous new infections, most of the episodes of the sinusitis were likely reactivation of the underlying viral pathogen. This type of patient most likely has enteroviruses especially in view of the respiratory and the GI involvement. The fatigue did not increase until later when he acquired another unique strain of enterovirus. There was likely a significant shift of the T-cell response downward to allow reactivation of underlying pathogens. The antibodies for Coxsackie B viruses and echoviruses (5/26 serotypes) were not significantly elevated. The biopsies from his stomach and colon tested positive for enterovirus VP 1 protein, a more specific indicator of persistent infection. Epigastric and right lower quadrant tenderness elicited by physical examinations correlated well with finding of enterovirus protein in the stomach biopsies, and therefore is a valuable sign to document in ME/CFS patients.
The patient was started back on another preparation of IVIG, which he tolerated well. He had improvement of the sinus symptoms but remained quite fatigued.
15-year-old white male had recurrent upper respiratory tract infection since early childhood. The patient developed asthma and was treated with steroids at least 3 or 4 times over the years. He was able to play soccer but would have at least a brief relapse with symptoms of coughing, sore throat and fatigue for 7-10 days after playing in a tournament.
He was functional until September 2007 when he had bedridden fatigue, global headache, sore throat, insomnia, sinus congestion and persistent cough after another episode of respiratory infections. The symptoms did not respond to antibiotics or Elavil.
The results of EBV and CMV antibodies were consistent with prior infection. DNA test for CMV and EBV and Lyme's disease antibody were negative. Thyroid function tests, CBC, chemistry panel were all normal or negative. The patient was evaluated by other physicians who all concluded that the patient had a diagnosis of pediatric chronic fatigue syndrome and subclass IgG deficiency. Immunologic workup by an immunologist showed a B-cell dysfunction in that there is deficient memory for immunoglobulin production. Immunization with pneumococcus vaccine and HIB showed a positive antibody response which declined at six months. He actually was started on IVIG but had a reaction to the specific preparation of IVIG. The patient was treated with numerous antibiotics Biaxin, Augmentin, Cipro and Zithromax but experienced questionable improvement. Sinus CT scan showed extensive inflammatory changes but no air-fluid level. Previous cultures of sinus drainage have all been negative. Intravenous antibiotics did not help his symptoms.
The patient also had upper stomach pain, nausea, fullness after eating, diarrhea at least one time per week. He underwent a colonoscopy and EGD with biopsy on February 14, 2007. Multiple biopsies of the esophagus, stomach, duodenum, terminal ileum and various parts of the colon showed minimal inflammation but with prominent lymphoid aggregates in practically every biopsy. The patient has not been able to attend school and could not participate in competitive soccer and is basically homebound. He continues to have all the above symptoms of headache, bedridden fatigue, mild myalgia.
Laboratory studies showed Coxsackie B-4 antibody of 1:160, echovirus antibodies were negative. CMV IgG, IgM are now negative. IgG subclass-3 is still low at 32. HHV-6 antibody was 1:160.
PHYSICAL EXAMINATION: Sinuses - mildly tender. Throat mildly inflamed without ulceration, thrush. Neck � minimal lymph nodes. Abdomen - mild epigastric and right lower quadrant tenderness. There is minimal muscle tenderness over the upper and lower extremities. Neurological - looks somewhat tired but otherwise normal.
ASSESSMENT & TREATMENT: Chronic fatigue syndrome in a pediatric patient with B-cell dysfunction, low IgG1, IgG3 levels. The patient had frequent respiratory infections since childhood complicated by asthma. The patient likely has a Th2-dominant response which could not eradicate viruses that become persistent in his body. Instead of having numerous new infections, most of the episodes of the sinusitis were likely reactivation of the underlying viral pathogen. This type of patient most likely has enteroviruses especially in view of the respiratory and the GI involvement. The fatigue did not increase until later when he acquired another unique strain of enterovirus. There was likely a significant shift of the T-cell response downward to allow reactivation of underlying pathogens. The antibodies for Coxsackie B viruses and echoviruses (5/26 serotypes) were not significantly elevated. The biopsies from his stomach and colon tested positive for enterovirus VP 1 protein, a more specific indicator of persistent infection. Epigastric and right lower quadrant tenderness elicited by physical examinations correlated well with finding of enterovirus protein in the stomach biopsies, and therefore is a valuable sign to document in ME/CFS patients.
The patient was started back on another preparation of IVIG, which he tolerated well. He had improvement of the sinus symptoms but remained quite fatigued.