Case Study 8
A 44 year-old female experienced a great deal of stress in 2000 when she worked as a teacher and assistant principle. She became more depressed and did not respond to anti-depressant. The patient was already fatigued, but did not seek medical help during her busy summer schedule. Myalgia and arthralgia started mainly in hands, wrists and muscles around the joints, which were migratory in nature. She noticed pain and spasms over her neck and both shoulders. The patient did not have fever, but did have mild chills and mild night sweats. She had unrefreshing sleep, cervical lymphadenopathy, sinus congestion, pharyngitis, chest pain, headache, diarrhea and severe fatigue.
A medical evaluation revealed shoddy cervical lymph nodes and diffuse muscle tenderness (trigger points). She was felt to have depression and fibromyalgia. A complete blood count, comprehensive chemistry panel, thyroid function test and erythrocyte sedimentation rate were normal and a work-up for autoimmune diseases was negative. IgG antibody to Epstein-Barr virus was positive with a negative IgM antibody. Treatment with Paxil did not alleviate her symptoms. She had frequent dizziness, unsteady gait and tingling of her hands. For the work-up of her abdominal complaints, EDG did show mild gastritis, which responded to Prilosec. A colonoscopic examination was negative.
Second rheumatology evaluation confirmed the diagnosis of fibromyalgia. The patient was treated with Ultram, Klonopin, Celexa, Trazadone, which did help the pain, sleep and depression. However, the fatigue continued. The patient tried Guaifenesin in the summer of 2002, but did not improve and experienced an increase of symptoms.
After she traveled to the east coast of the U.S., the symptoms of fatigue, myalgia worsened for 6 weeks. The symptoms would fluctuate every week, severe fatigue would last several days with energy level of 1-2/10, then gradually improve to a level of 4/10 on her best days. The patient had to quit working after one year of illness. The patient had to have a wheelchair to get around the house after she got back from her trip. All of the muscles and joints hurt after she performed trivial activity. Now, the maximal exercise she can perform is walking slowly for 15 minutes with post-exertional malaise whereas she could jog for miles. Before she became ill she would rarely need to take a nap, wheras now she must lie down very often. She slept poorly, awakening q 3 hours. Even doing her hair will make her tired. She lost 10 pounds since the onset of illness. The symptoms were much worse right before her periods. She would have 5 good days in a month.
Past Medical History.
Positive for IBS since 15 years of age. Shingles � several episodes over the upper and mid-back, treated with antivirals, last episode 8 years ago.
Physical Examination: Throat is mildly inflamed. Mildly tender neck lymph nodes. Adomen: Moderate epigastrium and lower quadrant tenderness.Neurological: Lying down on the examination table the whole time. Not grossly depressed. Normal examination except for slow response to questions and poor memory.
Special laboratory study:
Enterovirus studies: CVB4 antibody 1:320, CVB5 antibody 1:160. Enteroviral protein staining of the stomach biopsy showed 2+ staining (extensive) and the same biopsy grow non-cytopathic enterovirus in culture.
Assessment & Treatment:
Chronic fatigue syndrome and fibromyalgia � the patient's symptoms started around 2000 perhaps after a subclinical respiratory or GI infection. We have seen a number of patients who had prior histories of respiratory or GI infections and deteriorated without a clear-cut, new episode of viral infection. The symptoms of a new infection may have been interpreted as a flare of the prior infection. After complete evolution of the symptoms, enteroviral infection was suspected and confirmed by the study of the stomach biopsies. The patient was under a great deal of emotional stress, which could have shifted the immune response to the Th2 direction. The patient has fulfilled the 2 major and 4 minor criteria for the diagnosis of CFS, as established by the CDC in 1994. Based on evidences found in animal model of Coxsackie B virus infection and studies done by other investigators on patients with post-infectious fatigue syndrome, there is little doubt that persistence of viral RNA in susceptible, long-living cells can elicit chronic inflammatory reaction resulting in symptoms of CFS. The patient has not responded to interferon or a combination of Chinese herbs. Her insurance would not pay for IVIG.
A 44 year-old female experienced a great deal of stress in 2000 when she worked as a teacher and assistant principle. She became more depressed and did not respond to anti-depressant. The patient was already fatigued, but did not seek medical help during her busy summer schedule. Myalgia and arthralgia started mainly in hands, wrists and muscles around the joints, which were migratory in nature. She noticed pain and spasms over her neck and both shoulders. The patient did not have fever, but did have mild chills and mild night sweats. She had unrefreshing sleep, cervical lymphadenopathy, sinus congestion, pharyngitis, chest pain, headache, diarrhea and severe fatigue.
A medical evaluation revealed shoddy cervical lymph nodes and diffuse muscle tenderness (trigger points). She was felt to have depression and fibromyalgia. A complete blood count, comprehensive chemistry panel, thyroid function test and erythrocyte sedimentation rate were normal and a work-up for autoimmune diseases was negative. IgG antibody to Epstein-Barr virus was positive with a negative IgM antibody. Treatment with Paxil did not alleviate her symptoms. She had frequent dizziness, unsteady gait and tingling of her hands. For the work-up of her abdominal complaints, EDG did show mild gastritis, which responded to Prilosec. A colonoscopic examination was negative.
Second rheumatology evaluation confirmed the diagnosis of fibromyalgia. The patient was treated with Ultram, Klonopin, Celexa, Trazadone, which did help the pain, sleep and depression. However, the fatigue continued. The patient tried Guaifenesin in the summer of 2002, but did not improve and experienced an increase of symptoms.
After she traveled to the east coast of the U.S., the symptoms of fatigue, myalgia worsened for 6 weeks. The symptoms would fluctuate every week, severe fatigue would last several days with energy level of 1-2/10, then gradually improve to a level of 4/10 on her best days. The patient had to quit working after one year of illness. The patient had to have a wheelchair to get around the house after she got back from her trip. All of the muscles and joints hurt after she performed trivial activity. Now, the maximal exercise she can perform is walking slowly for 15 minutes with post-exertional malaise whereas she could jog for miles. Before she became ill she would rarely need to take a nap, wheras now she must lie down very often. She slept poorly, awakening q 3 hours. Even doing her hair will make her tired. She lost 10 pounds since the onset of illness. The symptoms were much worse right before her periods. She would have 5 good days in a month.
Past Medical History.
Positive for IBS since 15 years of age. Shingles � several episodes over the upper and mid-back, treated with antivirals, last episode 8 years ago.
Physical Examination: Throat is mildly inflamed. Mildly tender neck lymph nodes. Adomen: Moderate epigastrium and lower quadrant tenderness.Neurological: Lying down on the examination table the whole time. Not grossly depressed. Normal examination except for slow response to questions and poor memory.
Special laboratory study:
Enterovirus studies: CVB4 antibody 1:320, CVB5 antibody 1:160. Enteroviral protein staining of the stomach biopsy showed 2+ staining (extensive) and the same biopsy grow non-cytopathic enterovirus in culture.
Assessment & Treatment:
Chronic fatigue syndrome and fibromyalgia � the patient's symptoms started around 2000 perhaps after a subclinical respiratory or GI infection. We have seen a number of patients who had prior histories of respiratory or GI infections and deteriorated without a clear-cut, new episode of viral infection. The symptoms of a new infection may have been interpreted as a flare of the prior infection. After complete evolution of the symptoms, enteroviral infection was suspected and confirmed by the study of the stomach biopsies. The patient was under a great deal of emotional stress, which could have shifted the immune response to the Th2 direction. The patient has fulfilled the 2 major and 4 minor criteria for the diagnosis of CFS, as established by the CDC in 1994. Based on evidences found in animal model of Coxsackie B virus infection and studies done by other investigators on patients with post-infectious fatigue syndrome, there is little doubt that persistence of viral RNA in susceptible, long-living cells can elicit chronic inflammatory reaction resulting in symptoms of CFS. The patient has not responded to interferon or a combination of Chinese herbs. Her insurance would not pay for IVIG.