Chronic Fatigue Immune Dysfunction Syndrome (CFIDS) may be a cluster of related diseases that produce severe and persisting fatigue as one of the main symptoms. The CFIDS Society International refers to three criteria (similar to the definition developed at the Centers for Disease Control) for determining whether CFIDS is an appropriate designation for the disease experienced by an individual.
Origins of the Disease
It is unclear when CFIDS first arose. There are cases in the older
medical literature of severe fatigue with sudden onset, but it is not known
if one or more of the disorders described earlier is the same as CFIDS.
An epidemic disease, myalgic encephalomyelitis, was reported in Iceland
in 1948, and soon after reported in several places in Europe; it has been
suggested to be related to CFIDS. Discussion of "chronic fatigue syndrome,"
which eventually led to the definition of CFIDS, first became prevelant
in the late 1970's, around the same time that the AIDS virus began spreading
the U.S. and Europe; it was seriously reported in the medical literature
nearly ten years later, though there were pasing references to it in the
intervening years.
The possibility taht chronic fatigue syndrome was due to a herpes-type virus was raised when high Epstein-Barre Virus (EBV) titers were reported in several patients; the disorder known as chronic fatigue syndrome was, for a time, called chronic Epstein-Barr virus infection or syndrome. However, several studies have since revealed that EBV titers are no higher in people with CFIDS, than in others who not whoe signs of CFIDS. In recent years, new herpes viruses, such as HHV6, have been identified and are considered potentially serious disease-causing vectors; several of the herpes viruses reside in nerve cells, so it is certainly possible that they are involved in CFIDS. However, unlike AIDS, caused by HIV, or mononucleosis, caused by EBV, CFIDS, does not appear to follow any clear pattern of transmission from one person to another. Therefore, if a virus is involved, there may need to be significant initiating factors that lead to development of the syndrome.
EBV is still being investigated as a relevant viral infection; for example, it could be a transactivator of another virus that is directly involved in CFIDS pathogenesis, or it could be activated by such a virus to generate some of the symptoms. According to estimates, this virus infects 80-95% of the adult population by age 35. Most Americans acquire the virus during adolescence or young adulthood and the classic manifestation is infectious mononucleosis. Although the symptoms of mononucleosis usually resolve in one to two months, EBV remains a chronic infection which can be activated by a variety of factors. Cytomegalovirus (CMV, a virus similar to EBV); usually affects an older population with age-related immune depression, persons treated by immuno-suppressive drugs, new born babies who have not yet developed an immune response to the virus, and those infected by HIV, but it usually remains a low level infectious agent in those with only slightly abnormal immune responses. CMV can cause acute mononucleosis and symptoms similar to those found in CFIDS. Toxoplasmosis, a protozoal infection that is usually spread through eating undercooked meat or through exposure to cat feces, is also being investigated as a potential contributor to CFIDS; like CMV, it is usually not a cause of disease unless the immune system is suppressed. An immune-suppressing virus or a chemically-induced immune suppression would be a likely prerequsite for developing some of the secondary infections of concern via these other pathogens.
Human Herpes Virus 6 (HHV-6) has been found in peripheral blood mononuclear cells, and an immunomodulatory drug, poly(l).poly(C12U), decreases HHV-6 activity at the same time that clinical and neuropsychological improvement occurs. CFIDS, patients show elevated antiviral responses (possible an ineffective attempt to eliminate HHV-6) that also decline with clinical improvement. A double-blind placebo-controlled six month trial involving 92 CFIDS patients showed that this drug therapy could improve Karnofsky performance scores, increase ability to do exercise, improve cognitive function, and reduce dependence on other medications. While the studies support the use of this drug for CFIDS, HHV-6 is not necessarily the cause or cofactor: history of infection (indicated by presence of antibodies to HHV-6) has been found in 12.5% of healthy controls, 86% of patients with a variety of diseases under investigation, and 69% of CFIDS patients.
Chronic fatigue syndrome was dubbed "yuppie flu" for popular reference in the U.S. and called that until quite recently because it seemed to primarily affect relatively affluent, highly active, young adults (the term yuppie comes from the initials of young urban professionals). This apparently limited distribution of the disease led to suggestions that it was simply a psychological problem similar to the neurasthenia syndrome described over a hundred years ago to be the result of "modern stress". More recently, however, the disease has been found to have a somewhat wider distribution. Nonetheless, characteristics of the group most frequently affected may shed some light on the factors that lead to development of CFIDS. For example, CFIDS, mainly affects women (about 75-80% of cases), and the age of onset tends to be 25-50 years of age (the same as that for many autoimmune disorders), with a greater incidence in the range 25-40 years.
There are currently four factors that are considered potential triggers for CFIDS, along with exposure--or unique susceptibility--to one or mroe infectious agents:
1) Severe emotional stress or chronic depression, which appears to affect 50% or more of those with CFIDS. It is difficult to distinguish whether the psychological conditions are initiating factors, contributors to exacerbations, or simply a symptom of the disease, since depression, anxiety disorder, and panic disorder are among the neruopsychological symptoms of active CFIDS. It is well-established that emotional stress has a negative response on the immune system. In a study on breast cancer patients, the natural killer cell activity decreased in response to the increase in the amount of depression and the withdrawal of social support. By contrast, participation in support groups reduced depression and also decreased symptoms and increased survival time. It is expected that depression and emotional stressors can lead to viral activation or worsen the immune disorder. When cell mediated immune responses were compared in those with CFIDS, and those with major depression but without CFIDS, the prevalence and magnitude of the disturbance was found to be greater in those with CFIDS than without. Thus, while depression may be a contributor, it cannot itself be responsible for the full range of immune dysfunctions.
2) Chronic stress of the digestive system. For a large portion of the population, digestive stress begins early in life and persists for many years. Lack of breast-feeding or early weaning is typically followed by eating disorders involving diets too high in fats and simple sugars leading to an extraordinarily high obesity rate amongst young people that was particularly noted in the 1960's (President Kennedy strongly promoted fitness programs at the time) and which has been steadily worsening. Obesity and anorexia nervosa usually develop as overwhelming problems during the late teens and early twenties, though incidence of obesity at younger ages is increasing rapidly, as is the less frequent but equally serious problem of anorixia nervosa. The constant stress associated with characteristic American diets, combined with erratic eating patterns and nervous tension, often leads to the development of food sensitivities or allergies, and chronic bowel disorders (including "leaky gut syndrome"). Food sensitivities cna affect any organ system in teh boyd, resulting in many signs and symptoms taht resemble CIFIDS, including lethargy, aching joints, headaches, and lymphatic swelling. Numerous laboratory and lcinical studies have shown that improper diet leads to immunosuppression.
3) Environmental derangement of the immune system. Some individuals
believe that their experience of CIFDS, can be traced back to an episode
of exposure to a toxic chemical. Some industrial, research, and farm wrokers
have been repeatedly exposed to chemicals that accumulate to produce a
toxic syndrome. It is known that many drugs, such as corticosteroids, antihistamines,
and chemotherapeutic agents for cancer cause severe fatigue and immune
suppression as a side-effect, and this also applies to a number of environmental
pollutants. Some chemicals may alter DNA, activate viruses, or interfere
with normal metabolism. Problems of environmental contamination by heavy
metals, pesticides, and chemicals used for cleaning are among those that
could trigger immune dysfunctions. Lead poisoning, which affects the central
nervous system, became such a serious urban problem in the 1960's and 1970's
that legislative restrictions on lead in numberous products had to be instituted;
the neurological effects of lead poisoning are thought to persist for a
long time, especially when there are high blood levels early in life.
Exposure to ultra violet light (especially UVB) is known to depress
immune functions and to activate latent viruses (which may be the reason
that autoimmune flare-ups occur with exposure to UVB). A mechanism of viral
activation by oxidant chemicals and UV light has been elucidated: the nuclear
factor NF-kappa B is first activated by these environmental factors and
then this factor moves to the nucleus and initiates DNA processes, including
promotion of latent virus and oncogene replication cycles. UV light (and
several chemical pollutants) also acts directly on DNA, leading to an activation
of latent viruses and oncogenes. During the years just prior to initial
reports of chronic fatigue syndrome, and continuing until very recently,
there was a strong emphasis among the light=skinned population to develop
a sun tan. In fact, the "yuppie" population may have frequently indulged
in use of tanning booths and tropical vacations, leading to excessive UV
exposure. The development of CFIDS is paralleled by a rapid increase in
the incidence of skin cancer.
Another environmental factor of concern is the rapid rise in use of
estrogens and total body exposure to estrogen (delays in childbearing and
reduction in total number of children born lead to high total estrogen
exposure), which has been suggested to be associated with the continuing
rise in rates of breast cancer. Additionally, during the 1970's, in response
to an "energy crisis" (restricted crude oil supplies), homes and office
building were sealed to reduce heating/cooling expenses; indoor pollution
levels quickly rose, often exceeding those in city air. Such pollutants
could help activate latent viruses, depress cellular immunity, and worsen
allergies.
4) Overwork coupled with under-exercise. Overwork in the modern context
often refers to excessive mental activity (as opposed to physical labor)
under deadlines; this may put substantial stress on the adrenal gland.
At first one experiences a surge of energy, as the adrenal cortex releases
increased amounts of cortisol, so it is easy to do too much. But if a person
continually overworks, the adrenal output begins to fail, and both the
precursor of steroid hormones---DHEA (dehydroepiandrosterone), and cortisol
levels begin to fall. Decreased levels of cortisol are associated with
lethargy and fatigue (cortisol prevents overstimulation of the immune system)
as well as experience of peripheral aching. Patients with CFIDS often end
up having a decreased output of corticotropin releasing hormone (CRH).
This hormone is released in response to stress and helps to stimulate the
body's "fight or flight" response via norepinephrine, and it has a general
impact on all adrenal corticol hormones. A decrease in this hormone thus
leads to a decrease in exercise. This lower level of exercise contributes
to a lower metabolic rate and poor circulation, resulting in fatigue. The
fatigue associated with the syndrome further inhibits physical activity,
in a vicious cycle that eventually has a nearly paralyzing effect. It is
thought that the condition called "fibromyalgia", which sometimes accompanies
CFIDS, is due to poor microcirculation in the muscles, which is usually
relieved by exercise; however, too much exercise will exacerbate this condition,
probably because of the disturbed microcirculation which can not respond
to the demands of exercise. A small amount of necrotic tissue is detected
in muscle biopsy of those with CFIDS.
From what has been learned thus far, it is likely that a virus is a necessary precondition to experience CFIDS and that environmental influences, behavioral patterns, and/or adrenal exhaustion are necessary to trigger the full-blown immune dysfunction syndrome that is difficult to cure, while dietary stress, emotional disorders, and lack of exercise may be contributing factors to CFIDS and other cases of chronic fatigue. Additional syndromes may arise from the same types of factors, and may occur in association with CFIDS, including fibromyalgia, post-viral infection syndrome, and multiple chemical sensitivities. The appearance of CIFDS (or the increase in its frequency, making it a medical concern) comes at a time when there are increases in the incidence rates of early and late onset diabetes, childhood asthma, Parkinson's disease, testicular cancer, vulvar vestibulitis, and several other diseases for which similar factors may be responsible.
LABORATORY FINDINGS AND DIFFERENTIAL DIAGNOSIS
Although specific medical treatment for CFIDS has not yet been developed, it is considered very important to determine whether other diseases that may be the cause of teh sumptoms are present, and then to treat them specifically, if possible. The following tests should be conducted.
COMPLETE BLOOD COUNT (CBC): it is expected that there will be a decreased white blood cell count, increased lymphs or atypical lymphs on a peripheral smear. There may also be increased eosinophils if there is a major allergic condition. A CBC may reveal other abnormalities that would suggest a number of other possible diseases.
CHEMISTRY SCREEN: An examiniation of enzyme and chemical levels can be used to rule out hepatitis and other organic diseases which may cause fatigue and other symptoms characteristic of CFIDS.
THYROID PANEL (T4 AND TSH): This information can determine if hypothyroidism is present, which produces chronic fatigue, and which can be treated with supplemental thyroid hormone.
ADRENAL FUNCTION TEST: A saliva test can be conducted which is best for tracking the daily variation in cortisol levels. Levels of cortisol may be elevated or depressed in the AM or PM. This panel also measures DHEA, an adrenal hormone that may be lowered in CFIDS. The adrenal test will not necessarily indicate any particular disease, but it may suggest an appropriate treatment to rectify adrenal dysfunction.
MONONUCLEOSIS PANEL: IgG and IgM for EBV (CMV and toxoplasmosis can be tested by the same methodology). Viral capsid antigen (VCA, an antigen found in infected cells) is the test for EBV. VCA-IgG titers remain detectable for life, thus a good marker for past mononucleosis. VCA-IgM antibodies, on the other hand, decline to undectable levels 2-3 months after infection by EBV, and are a good marker for acute infection. Early antigen (EA; early antigens are produced in the infected cell within 24-48 hours) antibodies arise at about 5 weeks after infection and peak at 7-0 weeks. By 7-8 months, levels should be normal, though titers have been known to remain high for up to 4 years.), and nuclear antigen (NA; found in the nucleus of the cells. NA antibodies appear late in the illness, around 6-10 weeks, peaking at 10 months; they may remain persent for life.). Chronic infection by EBV, CMV, or toxoplasmosis can be treated by drug therapy, and possibly by herbal compounds.
ANTI-NUCLEAR ANTIBODY (ANA): This measure is used to rule out autoimmune diseases. Note some individuals with CFIDS, will have a lisghtly positive ANA, and all other factors associated with known autoimmune disorders will be negative. Autoimmune disorders are often treated with anti-inflammatory and immunosuppressive drugs; there are also many natural treatment strategies that can be applied.
STOOL TEST: A person with CFIDS may have parasites and/or candida, but these conditions may yield symptoms of digestive disturbance and fatigue in those without CFIDS, which are alleviated by reducing the levels of these organisms in the intestines. A stool test can reveal occult bleeding that may suggest the presence of a tumor.
HIV TEST: Rule out HIV infection, which presents similar symptoms. HIV infection may persist for ten years before causing obvious sumptoms; therefore, a person may consider themselves not at risk, yet they may have been at risk a decade ago.
CA-125 OR CEA: Rule out tumor growth. These blood tests are not as definitive as a CT scan for cancer, but may be used as an additional test for potential CFIDS patients to suggest that the reported symptomsa re not secondary to cancer development.
UNDERSTANDING CFIDS FROM A CHINESE PERSPECTIVE
Traditional Chinese doctors make frequent reference to symptoms of fatigue and exhaustion. While none of the traditional disease categories quite fits CFIDS, there are some parallels that can be explored.
Based on the experience of one of the current authors (E.V.) with CIFDS patients over a 10-year period, the typical presentation of CFIDS, is deficiency of spleen qi with some dampness, and kidney exhaustion. Spleen qi deficiency can lead to accumulation of dampnesss which may initially present only minor symptoms. Both teh spleen qi deficiency and the dampness may be caused by, or worsened by, dietary factors. Because of its heaviness, dampness tends to descend and its accumulation will most often be found in teh lower abdomen. For women, the group most often affected by CFIDS, the manifestations may include persistent vaginal or urinary tract infections (or irritable conditions without infection), as wel as bowel disorders. The stagnated dampness will block the normal circulation of qi, and this may be complicated by pre-existing problems of qi circulation or the impact of emotionally stressful situations. The stagnated qi and moisture can give rise to pathological heat and phlegm. Because heat tends to rise, the secondary manifestation of such a disorder may include respiratory system congestion (with or without obvious infection). Sinus disorders associated with this pattern will often worsen with ingestion of certain foods (e.g. fatty foods), and will be unresponsive to antibiotic therapies (indeed, the antibiotic therapy is thought to weaken the spleen qi and thus will worsen the disease pattern). The hot phlegm can also obstruct the orifices of the heart (and the channel connecting kidney and heart), producing insomnia and mental disorders. The phlegm-damp may produce masses (lymph node swelling, thyroid swelling, breast lumps). In some cases, the stagnation of qi will elad to blood stasis, with the formation of firm masses or with sumptoms of pain, dry skin, and numerous other conditions. The stagnation in the lower abdomen has a weakening effect on the kidney system, which may already be weakened as a pre-existing condition that makes the manifestation of CFIDS possible. Both spleen qi deficiency and kidney exhaustion are associated with low production of blood cells, lowered immune responses, poor memory, aching, and reduced libido and energy.
There is a disorder defined in the ancient and modern Chinese literature as Taxation Syndrome (xulao). This term is applied to any kind of chronic debilitating disease, such as tuberculosis and aplastic anemia, which will involve severe fatigue as a symptom and may lead to weight loss (due to loss of appetite, sweating and internal degereration). In classical sources, Xulao is described as an exhaustion of all organ networks, and a deficiency of qi, blood yin and yang. In general, xulao refers to a chronic state of exhaustion that does not go away when simply resting. Simple fatigue, on the other hand, disappears when one takes time out for rest and relaxation. Although xulao implies a deficiency condition, it may arise from an excess condition. Thus, there may be deficiency (spleen or kidney qi deficiency being the probable) or a combination of deficiency and excess (liver qi stagnation resulting in spleen qi weakness) or an excess condition (stagnation of qi and blood, accumulation of dampness).
The blood stasis syndrome may appear in prolonged CFIDS. An extended experience of CFIDS is what is commonly presented to practitioners of Chinese medicine after numerous other practitioners have been consulted with unsatisfactory therapeutic results. Blood stasis is recognized as a common feature of chronic hepatitis B infeciton, many autoimmune disorders, as well as other chronic diseases.
Herbal treatment of CFIDS can be very successful. However, one must watch the progress of the patient to be able to change the formula when patterns shift. Treatment time to resolve major CFIDS symptoms is typically six months, but one must then continue to treat the patient even though they appear well, as their fundamental qi is weak; otherwise there may be a relapse.
IT IS CLEAR THAT A PROPPER DIFFERENTIATION OF THE SYNDRONE IN IMPERATIVE FOR THE PROPER RESULTS. Please refer to my home page on Traditional Chinese medicine
FOOD SENSITIVITIES
A common response to foods for which a person is sensitive is fatigue. The most common food sensitivities are dairy (especially lactose), wheat and corn (though other grains may be problematic), eggs (especially the whites), and tomatoes. However, any food eaten with enough repetition may cause a reaction. Food sensitivities may have effects any part of the body, and not just the digestive organs. Although it is unlikely that food sensitivities directly cause CFIDS, they can play a role in suppressing the immune system and aiding the perpetual exhaustion a person feels. To test for food sensitivities, the RAST test and the ELISA test (IgG, IgM) are considered reliable methods. If food allergies are found, a six week avoidance diet followed by a rotation diet is typical practice among naturopathic physicians. The rotation diet should be continued for several months.
ELIMINATION OF FOODS
In general, elimination or reduction of caffeine (which decreases lymphocytic response), alcohol (impairs cell-mediated immunity), and refined sugar and flour (rapid absorption of simple sugars causes insulin stress and secondary reactions) is beneficial for persons with CFIDS.
EXERCISE
It is important to do moderate exercise, when possible. This strengthens the body, increases the blood flow, and decreases stress and fatigue. A regular routine is best, concentrating on strengthening and cardiovascular work out.
COUNSELLING:
Emotional response to having any chronic illness may include disorientation, depression, anxiety, and sense of hopeless at times; with CFI DS, the pathophysiology of the disease further reinforces these responses. One needs to gain perspective that it is a disease process that may require prolonged therapy, but it is not a permanent condition. Counseling is an excellent way to relieve the chronic stress of a long term illness. It is a place to help one gather the tools necessary to deal with CFIDS, to build a stress reduction plan, and to "let out" the worries, fears, and anger about being chronically !II. According to the principles of Chinese medicine, it is believed that for the qi to spread evenly and nourish the body, the emotions must also flow smoothly.