Case Study 4
42-year-old white male who developed a viral illness in 1986 that lasted at least one year. The nature of the illness was an upper respiratory infection associated with weakness, drowsiness, fatigue, sniffles, postnasal drip, dizziness and some weight gain. He did have purulent sputum, which was treated with antibiotics, but the patient continued to have significant respiratory congestion. Sinequan did help the insomnia and his energy level. He essentially recovered in October 1987. The symptoms recurred in April 2003. The episode lasted at least two months, started off with sinus infection then profound fatigue. He eventually recovered but still felt somewhat sluggish for several months. In September 2003 the fatigue recurred with swollen left eyelid but did not have any significant eye disease by examination. The fatigue actually improved after a cortisone shot followed by Medrol dosepak. The patient went back to work and yet the symptoms recurred in late December associated with insomnia and GI upset but no diarrhea.
EGD and colonoscopy in January in 2004 showed no significant abnormalities. Biopsy of the stomach showed minimal inflammatory changes. The patient could not get out of bed on most days. He had occasional night sweats associated with increased fatigue, intense myalgia (muscle soreness), mild cognitive dysfunction, post-exertional malaise and unrefreshing sleep.
Previous laboratory testing was essentially normal except for intermittent elevated liver enzyme to 65 (normal <40) in March 2003. Review of his blood work showed negative rheumatoid factor, anti-nuclear antibody, erythrocyte sedimentation rate. Repeat testing in September 2003 showed EBV VCA IgG of 47, negative IgM; normal CBC. Previous sinus CT on September 8, 2003 showed some paranasal sinus disease and a cyst in the right maxillary sinus. ALT was elevated at 61 in January 2004 but other aspects of the chemistry panel, CBC, TSH were again normal. Coxsackievirus B1-6 and Echovirus 6,79,11,30 antibody titers were negative.
PHYSICAL EXAMINATION: The patient looked mildly fatigued; not depressed. Vital signs normal. The general examination was normal except for minimal throat erythema, minimally tender cervical lymph nodes and moderate tenderness of the epigastrium, right lower and left lower abdomen. No muscle tenderness or trigger points were demonstrated.
Stomach biopsy done in 2004 was positive for enterovirus protein when performed in 2007.
ASSESSMENT & TREATMENT: Chronic recurrent fatigue began as an initial episode in 1986 lasting one year. The nature of the infection was not typical of EBV infection and the low EBV antibody was consistent with this assessment. Acute EBV infection, or acute mononucleosis, does not present with nasal or sinus congestion, rhinorrhea. This initial virus infection was probably enterovirus since other respiratory viruses, such as adenoviruses, coronaviruses, influenza, parainfluenza, RSV or metapneumovirus typically would not cause symptoms in immunocompetent patients for more than few weeks. The symptoms recurred few times over the next 20 years, mostly brought on by another respiratory infection. The GI symptoms were largely dismissed as irritable bowel syndrome and treated symptomatically. The stomach symptoms, such as nausea, indigestion, acid reflux, bloating with or without meals are suggestive of chronic enterovirus infection, which was confirmed by enteroviral staining of his stomach biopsy when the technique was developed. The patient was treated with a combination of alpha and gamma interferon for one month and went into remission for about one and a half years.
42-year-old white male who developed a viral illness in 1986 that lasted at least one year. The nature of the illness was an upper respiratory infection associated with weakness, drowsiness, fatigue, sniffles, postnasal drip, dizziness and some weight gain. He did have purulent sputum, which was treated with antibiotics, but the patient continued to have significant respiratory congestion. Sinequan did help the insomnia and his energy level. He essentially recovered in October 1987. The symptoms recurred in April 2003. The episode lasted at least two months, started off with sinus infection then profound fatigue. He eventually recovered but still felt somewhat sluggish for several months. In September 2003 the fatigue recurred with swollen left eyelid but did not have any significant eye disease by examination. The fatigue actually improved after a cortisone shot followed by Medrol dosepak. The patient went back to work and yet the symptoms recurred in late December associated with insomnia and GI upset but no diarrhea.
EGD and colonoscopy in January in 2004 showed no significant abnormalities. Biopsy of the stomach showed minimal inflammatory changes. The patient could not get out of bed on most days. He had occasional night sweats associated with increased fatigue, intense myalgia (muscle soreness), mild cognitive dysfunction, post-exertional malaise and unrefreshing sleep.
Previous laboratory testing was essentially normal except for intermittent elevated liver enzyme to 65 (normal <40) in March 2003. Review of his blood work showed negative rheumatoid factor, anti-nuclear antibody, erythrocyte sedimentation rate. Repeat testing in September 2003 showed EBV VCA IgG of 47, negative IgM; normal CBC. Previous sinus CT on September 8, 2003 showed some paranasal sinus disease and a cyst in the right maxillary sinus. ALT was elevated at 61 in January 2004 but other aspects of the chemistry panel, CBC, TSH were again normal. Coxsackievirus B1-6 and Echovirus 6,79,11,30 antibody titers were negative.
PHYSICAL EXAMINATION: The patient looked mildly fatigued; not depressed. Vital signs normal. The general examination was normal except for minimal throat erythema, minimally tender cervical lymph nodes and moderate tenderness of the epigastrium, right lower and left lower abdomen. No muscle tenderness or trigger points were demonstrated.
Stomach biopsy done in 2004 was positive for enterovirus protein when performed in 2007.
ASSESSMENT & TREATMENT: Chronic recurrent fatigue began as an initial episode in 1986 lasting one year. The nature of the infection was not typical of EBV infection and the low EBV antibody was consistent with this assessment. Acute EBV infection, or acute mononucleosis, does not present with nasal or sinus congestion, rhinorrhea. This initial virus infection was probably enterovirus since other respiratory viruses, such as adenoviruses, coronaviruses, influenza, parainfluenza, RSV or metapneumovirus typically would not cause symptoms in immunocompetent patients for more than few weeks. The symptoms recurred few times over the next 20 years, mostly brought on by another respiratory infection. The GI symptoms were largely dismissed as irritable bowel syndrome and treated symptomatically. The stomach symptoms, such as nausea, indigestion, acid reflux, bloating with or without meals are suggestive of chronic enterovirus infection, which was confirmed by enteroviral staining of his stomach biopsy when the technique was developed. The patient was treated with a combination of alpha and gamma interferon for one month and went into remission for about one and a half years.