Case Study 7
A 17-year-old white male had frequent infections as a child. The patient experienced sore throats at least 1-2 times a year, and then developed asthma at age 7, which was treated with inhalers. He started feeling tired along with experiencing thigh and leg pain since about 4-5 years ago. The patient recalled he and his brother became ill with vomiting, diarrhea, abdominal pain after eating at a local Mexican restaurant. The parents did not get sick. The patient was hospitalized for one day and sometime later developed fatigue, difficulty with concentration, deep pressure-like headaches along with nausea and indigestion, but no sore throat. His energy level has been about 3/10. The patient could go to school from 8:00AM to 3:00PM, but after school falls asleep for a long time and sometimes sleeps till the next morning. The brother also developed intermittent epigastric pain and mild fatigue.
Laboratory studies included repeated complete blood counts and chemistry panels in February and March 2008, which showed normal results. IgG level, IgA level, TSH, FSH, T4, testosterone levels were also normal. ANA, ESR, RF were negative with a normal CH-50. A rheumatologist felt the patient did have fibromyalgia. The patient was treated with Elavil and Neurontin with mild improvement. The patient did not respond to bio-feedback/hypnosis. He was found to be allergic to cat and dog danders, olive trees, etc. Six months ago the patient developed symptoms of viral meningitis which were treated symptomatically as an outpatient. After this episode, the patient developed marked increase in fatigue, postexertional malaise, poor sleep with frequent awakening at night. He did have night sweats, mild arthralgia along with the myalgia, but no rashes. His grades worsened with increasing cognitive dysfunction. The patient did see Dr. St. Amand who felt the patient had fibromyalgia, but a 6-month course of guaifenesin did not help his symptoms. The patient has tried Soma and Flexeril which made him more tired.
PAST MEDICAL HISTORY: Acute mononucleosis 2 years ago.
PHYSICAL EXAMINATION: Sinuses non-tender. Nostrils minimally inflamed. Ears normal. Mouth 0.7 x 0.7 centimeter follicular erythematous swelling over the oropharynx. No other ulceration, thrush. Neck: shotty AC/PC lymph nodes, mildly tender; no thyromegaly. Lungs and heart normal. Abdomen: mild but significant epigastric and right lower quadrant tenderness. Extremities: without edema, clubbing or cyanosis; minimally tender over the upper and lower extremities. Neurological: the patient does look tired but able to sit on the examination table most of the time. Cranial nerves II-XII within normal limits. Motor strength equal on both sides. Reflexes normal. Gait, Romberg negative.
Stomach biopsy showed extensive enteroviral protein by staining.
ASSESSMENT & TREATMENT: Chronic fatigue syndrome following repeated virus infection. At age 7 the patient developed asthma following virus infection which is indicative of th2 response. 4 or 5 years ago the patient developed vomiting and diarrhea after eating Mexican food which was followed by fatigue, myalgia, CNS dysfunction, etc. The GI involvement and other symptoms of CFS are highly suggestive of chronic enterovirus infection, which worsened after developing viral meningitis six months ago. The most common agent causing viral meningitis is enterovirus. After repeated enterovirus infections, the patient seemed to do much worse. The patient had minimal improvement of symptoms after IVIG, but now doing much better on oxymatrine, a Chinese herbal supplement.
A 17-year-old white male had frequent infections as a child. The patient experienced sore throats at least 1-2 times a year, and then developed asthma at age 7, which was treated with inhalers. He started feeling tired along with experiencing thigh and leg pain since about 4-5 years ago. The patient recalled he and his brother became ill with vomiting, diarrhea, abdominal pain after eating at a local Mexican restaurant. The parents did not get sick. The patient was hospitalized for one day and sometime later developed fatigue, difficulty with concentration, deep pressure-like headaches along with nausea and indigestion, but no sore throat. His energy level has been about 3/10. The patient could go to school from 8:00AM to 3:00PM, but after school falls asleep for a long time and sometimes sleeps till the next morning. The brother also developed intermittent epigastric pain and mild fatigue.
Laboratory studies included repeated complete blood counts and chemistry panels in February and March 2008, which showed normal results. IgG level, IgA level, TSH, FSH, T4, testosterone levels were also normal. ANA, ESR, RF were negative with a normal CH-50. A rheumatologist felt the patient did have fibromyalgia. The patient was treated with Elavil and Neurontin with mild improvement. The patient did not respond to bio-feedback/hypnosis. He was found to be allergic to cat and dog danders, olive trees, etc. Six months ago the patient developed symptoms of viral meningitis which were treated symptomatically as an outpatient. After this episode, the patient developed marked increase in fatigue, postexertional malaise, poor sleep with frequent awakening at night. He did have night sweats, mild arthralgia along with the myalgia, but no rashes. His grades worsened with increasing cognitive dysfunction. The patient did see Dr. St. Amand who felt the patient had fibromyalgia, but a 6-month course of guaifenesin did not help his symptoms. The patient has tried Soma and Flexeril which made him more tired.
PAST MEDICAL HISTORY: Acute mononucleosis 2 years ago.
PHYSICAL EXAMINATION: Sinuses non-tender. Nostrils minimally inflamed. Ears normal. Mouth 0.7 x 0.7 centimeter follicular erythematous swelling over the oropharynx. No other ulceration, thrush. Neck: shotty AC/PC lymph nodes, mildly tender; no thyromegaly. Lungs and heart normal. Abdomen: mild but significant epigastric and right lower quadrant tenderness. Extremities: without edema, clubbing or cyanosis; minimally tender over the upper and lower extremities. Neurological: the patient does look tired but able to sit on the examination table most of the time. Cranial nerves II-XII within normal limits. Motor strength equal on both sides. Reflexes normal. Gait, Romberg negative.
Stomach biopsy showed extensive enteroviral protein by staining.
ASSESSMENT & TREATMENT: Chronic fatigue syndrome following repeated virus infection. At age 7 the patient developed asthma following virus infection which is indicative of th2 response. 4 or 5 years ago the patient developed vomiting and diarrhea after eating Mexican food which was followed by fatigue, myalgia, CNS dysfunction, etc. The GI involvement and other symptoms of CFS are highly suggestive of chronic enterovirus infection, which worsened after developing viral meningitis six months ago. The most common agent causing viral meningitis is enterovirus. After repeated enterovirus infections, the patient seemed to do much worse. The patient had minimal improvement of symptoms after IVIG, but now doing much better on oxymatrine, a Chinese herbal supplement.