Unraveling Chronic Fatigue Syndrome

Unraveling Chronic Fatigue Syndrome

Oh, fatigue! That dog tired, energy zapping malaise that often accompanies a period of stress or overexertion is a feeling everyone experiences occasionally. Chronic fatigue syndrome, however, is not the ups and downs we experience in everyday life. This debilitating disease does not go away but slowly robs a person of vigor and ultimately health over the course of months and often years.

Defining CFS

Chronic fatigue syndrome is a poorly understood disorder with a reported prevalence of up to 3 out of 1000 population. The syndrome is defined as profound fatigue lasting at least six months, often beginning abruptly after an acute vital infection and not meeting the criteria for other medical or psychiatric disorders. Fatigue is characteristically worse following levels of physical exertion that had been easily tolerated in the past. Other prominent features of this clinically defined syndrome include lightheadedness and difficulty concentrating. No single diagnostic test has been developed for CFS and no therapy has proven consistently effective.

Chronic fatigue syndrome is a clinically-defined condition characterized by severe disabling fatigue and a combination of symptoms that prominently features self-reported impairments in concentration and short-term memory, sleep disturbances, and musculoskeletal pain. Shown in Tables 1 and 2 are a list of criteria and the most frequently encountered symptoms in patients with CFS.

It has been associated with necrologic problems and a constellation of symptoms that can resemble many disorders including mononucleosis, multiple sclerosis, fibromyalgia, and AIDS, Lyme's disease, post-polio syndrome, and autoimmune diseases such as lupus.

CFS is also known as chronic fatigue immune dysfunction syndrome (CFIDS) because a number of immunologic abnormalities have been reported. The disease has also been referred to as the chronic Epstein-Bart virus syndrome, the myalgic encephalomyelitis syndrome, the "yuppie flu" and other names. In Japan, the condition is known as low natural killer syndrome, or LNKS.

Similar syndromes known by different names date back to the late 1800s. The modern stereotype arose because those who sought help for and stimulated scientific interest in CFS in the early 1980s were mainly well-educated, affluent women in their 30s and 40s. Since then, physicians have seen the syndrome in people of all ages, races, and socioeconomic classes from several countries around the world. CFS is diagnosed two to four times more often in females than in males.

Possible causes

Although the precise cause is unknown, there appears to be a dysfunction of the neuroendocrine immunologic (NEI) network.

One line of research suggests that the syndrome results from a dysfunction of the immune system. Several subtle immunologic abnormalities have been described in patients with CFS. These include low levels of specific immunoglobulins reported in 17 to 71 percent. Other studies have reported a decrease in natural killer (NK) cells in several patients. These NK cells appear to play a major role in the host defense against viral infection. Preliminary data strongly suggests the possibility of modest immunologic dysfunction occurring in a proportion of CFS patients.

The second line of research suggests that CFS may be the result of neurally mediated hypotension (NMH), or low blood pressure. In CFS patients, blood pressure is not mediated when patients go from a reclining to an upright position. The system appears to be defective, resulting in fatigue. Studies by the Hopkins group have shown an abnormal response in patients with CFS compared with controls.

The third but not mutually exclusive theory is one that suggests a metabolic involvement. Owing to stress, viral infection, or a host of other factors, patients with CFS have increased synthetase and RNAse L activity, which leads to the depletion of cellular ATP. This depletion may be responsible for the severe fatigue, cognitive disturbances and other manifestations of the syndrome.

How is CFS diagnosed?

Since the etiology of the syndrome is unknown, there are no definitive diagnostic tests for CFS. The diagnosis is made on clinical criteria, i.e., symptoms as described in Tables 1 and 2. The following is the diagnostic approach which we use at Georgetown:

Careful history
Thorough physical exam
Appropriate lab tests
Treatment options

Based on these considerations, a number of new studies have appeared which have suggested new lines of therapy. Using the viral theory as a basis, several studies have now suggested the use of antiviral drugs (acyclovir, famcyclovir, gancyclovir). To date, these drugs have not shown uniform benefit but may in individual cases be useful.

At Georgetown, we have utilized another antiviral approach including the use of interferon-alpha (IFN-a) 1.0 x 10(6) units three times per week, administered subcutaneously for a period of 6 to 8 weeks. Interferon is a natural substance protein we all make in our bodies. It's antiviral and adjusts the immune system. That's the basis of using it for CFS. In a selected group of 115 patients who were initially screened, 14 were treated with IFN-a showed a significant improvement in 70 percent of cases. A similar beneficial response using IFN-a has been reported by Brook et. al. (1993) in the Journal of Infectious Diseases.

Based upon the metabolic theory, the Georgetown group has recently completed a double-blind placebo controlled cross-over study of a co-enzyme NADH. The proposed mechanism of action of the co-enzyme is to replenish the depleted cellular stores of ATP, thus improving the fatigue and cognitive dysfunction. The control of allergic disease is critical in the management of patients with CFS since exacerbations of untreated allergic disease have clearly aggravated the clinical course of CFS.

A significant percentage of patients with CFS show marked improvement over time but the course tends to include relapses, particularly when patients overexert themselves, experience intercurrent infections or aggravation of allergies. Rest, good nutrition, light exercise are helpful.

"We got very good results with NADH," he said. "Taking it in supplement form is easy for patients. We really enjoyed working with Dr. Birkmayer, also." Dr. Georg Birkmayer and Menuco hold the patent on NADH, the only stabilized form of NADH. The co-enzyme has also been the subject of clinical trials for Alzheimer's, depression and athletic endurance.

Is CFS contagious?

It is probable that the virus or viruses or other agents which cause this disorder are transmitted from person to person. The degree of communicability, however, appears to be low since most people who live in close contact with CFS patients rarely develop the illness. Reports of "cluster" in families, workplaces, and communities have been described.

Living with CFS

The socioeconomic effect of CFS-afflicted patients can be dramatic. Many are so severely affected that they are forced to quit work for months to years at a time or lose their jobs because they cannot do their duties. They often cannot qualify for disability benefits because the illness is not recognized as a legitimate disease in many areas. Many become socially isolated because they are thought to have a contagious disease.

Treatment options

Finding a physician knowledgeable and willing to treat patients with CFS can be difficult. These patients require lengthy clinical sessions and time for discussion and work-up. Because the symptoms are not organ specific, no single medical discipline has embraced the disease. The careful management of allergic disease and other environmental factors can lead to a striking improvement.

"Stretching is extremely important to get blood flowing and to eliminate toxins," Bellanti said. "Also, drink plenty of fluids."

He said Chinese herbal medicine, which is the basis for many modern drugs, may also be helpful to individuals. "I know organized medicine has been traditionally down on herbal medicine, but we have to be more expansive in our thinking."

Measurements & Data Corporation.

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By Joseph A. Bellanti

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